Information Collection

Sf 2812a

IC 209210 under ICR 201305-3206-001 · OMB 3206-0262.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0262 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SF 2812A SF 2812A	Form and Instruction
SF 2812A Report of Withholdings and Contributions for Health Bene sf2812a.pdf	Form and Instruction

IC Title:

SF 2812A

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	SF 2812A	Report of Withholdings and Contributions for Health Benefits by Enrollment Code	sf2812a.pdf		Yes	Yes	Fillable Printable

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,600	2,600
Annual IC Time Burden (Hours)	1,300	1,300
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.