Form 8963, Report of Health Insurance Provider Information

REG-118315-12 (FINAL), Health Insurance Providers Fee and Form 8963, Report of Health Insurance Provider Information

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.