Information Collection

TRICARE Young Adult Application

IC 197033 under ICR 201105-0720-001 · OMB 0720-0049.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.