Model Employer CHIP Notice (State, Local, Tribal Governmental Burden)

Model Employer Children's Health Insurance Program Notice

OMB: 1210-0137

IC ID: 208807

Documents and Forms
Document Name
Document Type
Other-Model Notice
Information Collection (IC) Details

View Information Collection (IC)

Model Employer CHIP Notice (State, Local, Tribal Governmental Burden)
 
No New
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Model Notice chipmodelnotice_7-31-13.doc www.dol.gov/ebsa/chipmodelnotice.doc Yes Yes Printable Only

Income Security General Retirement and Disability

 

76,000 0
   
State, Local, and Tribal Governments
 
   38 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,222,846 0 0 2,222,846 0 0
Annual IC Time Burden (Hours) 11,481 0 0 11,481 0 0
Annual IC Cost Burden (Dollars) 275,637 0 0 275,637 0 0

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