Information Collection

Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction

IC 188224 under ICR 201210-1210-002 · OMB 1210-0135.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form 300 Request to the Department of Labor for Expedited Review of Denial of COBRA Premium Reduction	Form and Instruction
Form 300 Application to U.S. Department of Labor for Expedited Re AARA COBRA.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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 and Instruction	Form 300	Application to U.S. Department of Labor for Expedited Review of Denial of COBRA Premium Reduction	AARA COBRA.pdf		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 167

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 38 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	167	-13,833	14,000
Annual IC Time Burden (Hours)	167	-13,833	14,000
Annual IC Cost Burden (Dollars)	104	-7,896	8,000

Documents for IC

table that charts IC Documents
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.