Information Collection

HCTC Medicare Family Member Registration Form

IC 191173 under ICR 201308-1545-008 · OMB 1545-2162.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 14117 HCTC Family Member Registration HCTC Medicare Family Member Registration Form	Form and Instruction
14117 HCTC Family Member Registration Form14117_OCT2012.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	14117				Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,400	0	2,400
Annual IC Time Burden (Hours)	600	-600	1,200
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.

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