TRICARE Young Adult Application

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0049 can be found here:

Documents and Forms

Document Name Document Type
Form ddx605 TRICARE Young Adult Application Form
ddx605 TRICARE YOUNG ADULT APPLICATION ddx605.pdf Form
A - MFR SSN Justification-TRICARE Young Adult.pdf SSN Justification IC Document
Statement of Determination.doc Statement of Determination IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	TRICARE Young Adult Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 199

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	ddx605	TRICARE YOUNG ADULT APPLICATION	ddx605.pdf		Yes	No	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 16,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	32,000	32,000
Annual IC Time Burden (Hours)	8,000	8,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSN Justification	A - MFR SSN Justification-TRICARE Young Adult.pdf	03/22/2011
Statement of Determination	Statement of Determination.doc	03/22/2011

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