Information Collection

Affordable Care Act Enrollment Opportunity Notice Relating to Extension of Dependent Coverage

IC 192671 under ICR 201011-1210-003 · OMB 1210-0139.

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Document Name	Document Type

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IC Title:

Affordable Care Act Enrollment Opportunity Notice Relating to Extension of Dependent Coverage

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 29 CFR 2590.715-2714(f)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,800,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 38 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	79,573,000	79,573,000
Annual IC Time Burden (Hours)	411,000	411,000
Annual IC Cost Burden (Dollars)	1,233,500	1,233,500

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.