Information Collection

Third Party Collection Program (Insurance Information)

IC 5378 under ICR 201304-0720-001 · OMB 0720-0055.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0055 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD-2569 Third Party Collection Program (Insurance Information)	Form
DD-2569 Third Party Collection Program/Medical Services Account/ dd2569.pdf	Form

IC Title:

Third Party Collection Program (Insurance Information)

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 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-2569	Third Party Collection Program/Medical Services Account/Other Health Insurance	dd2569.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: 3,507,390

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,507,390	700,178	2,807,212
Annual IC Time Burden (Hours)	175,370	35,009	140,361
Annual IC Cost Burden (Dollars)	0	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.