Information Collection

Form 13560, HCTC Health Plan Administrator (HPA) Return of Funds Form

IC 19574 under ICR 201011-1545-016 · OMB 1545-1891.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-1891 can be found here:

Documents and Forms

Document Name Document Type
Form 13560 Form 13560, HCTC Health Plan Administrator (HPA) Return of Funds Form Form and Instruction
13560 Health Plan Administrator (HPA) Return of Funds Form 13560.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Form 13560, HCTC Health Plan Administrator (HPA) Return of Funds Form	Agency IC Tracking Number:	EC-1545-1891-016

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	13560	Health Plan Administrator (HPA) Return of Funds Form	13560.pdf		No		Paper Only

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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