TRICARE Retiree Dental Program Enrollment Appication

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0015 can be found here:

Documents and Forms

Document Name Document Type
Form Delta Dental Form TRICARE Retiree Dental Program Enrollment Appication Form
Delta Dental Form TRICARE Retiree Dental Program Enrollment Application MM042 App 0911 B.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	TRICARE Retiree Dental Program Enrollment Appication	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 199.22

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	Delta Dental Form	TRICARE Retiree Dental Program Enrollment Application	MM042 App 0911 B.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 64,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 35 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	64,000	-7,332	71,332
Annual IC Time Burden (Hours)	16,000	-1,833	17,833
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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