Information Collection

Third Party Collection Program/Medical Services Account/Other Health Insurance

IC 206286 under ICR 201303-0720-002 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD Form 2569 Third Party Collection Program/Medical Services Account/Other Health Insurance	Form
DD Form 2569 Third Party Collection Program/Medical Services Account/ dd2569Feb2011version.pdf	Form

IC Title:

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 220

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	DD Form 2569	Third Party Collection Program/Medical Services Account/Other Health Insurance	dd2569Feb2011version.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title: DHA12

FR Citation: 75 FR 79345

Number of Respondents: 2,936,905

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 35 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,936,905	2,936,905
Annual IC Time Burden (Hours)	146,845	146,845
Annual IC Cost Burden (Dollars)	0	0

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.