Information Collection

(149.35(b)(2)) - Written Agreement with Issuer or Plan

IC 201221 under ICR 201202-0938-004 · OMB 0938-1087.

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Information Collection (IC) Details

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IC Title:	(149.35(b)(2)) - Written Agreement with Issuer or Plan	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 149.35(b)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Early Retiree Reinsurance Program	FR Citation: 75 FR 31440

Number of Respondents: 1,528	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: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,528	1,528
Annual IC Time Burden (Hours)	1,528	1,528
Annual IC Cost Burden (Dollars)	0	0

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