Information Collection

Form 8963, Report of Health Insurance Provider Information

IC 210140 under ICR 201401-1545-021 · OMB 1545-2249.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2249 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 8963 Form 8963, Report of Health Insurance Provider Information	Form
Instr for Form 8963.pdf	Instruction
8963 Report of Health Insurance Provider Information Form 8963.pdf	Form

IC Title:

Form 8963, Report of Health Insurance Provider Information

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	8963	Report of Health Insurance Provider Information	Form 8963.pdf		Yes	Yes	Fillable Fileable
Instruction			Instr for Form 8963.pdf		Yes	No	Printable Only

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: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	17,808	17,808
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.