Annual Information Return/Report

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form 5500 Multiple Employer Welfare Arrangements Revisions of Form 5500	Form and Instruction	Unchanged	Available
Justification for Nonmaterial Nonsubstantive Change 3-26-14.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2014-03-26	Available
EBSAF5500ss 020113.docx	Supporting Statement A	Uploaded 2013-02-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205399	Multiple Employer Welfare Arrangements Revisions of Form 5500	Form and Instruction	Unchanged
13467	Annual Information Return/Report	Instruction	Modified

ICR Details

OMB Control No: 1210-0110	ICR Reference No: 201403-1210-001
Status: Historical Active	Previous ICR Reference No: 201311-1210-003
Agency/Subagency: DOL/EBSA	Agency Tracking No:
Title: Annual Information Return/Report
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/27/2014
	Date Received in OIRA: 03/26/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2016	05/31/2016	05/31/2016
Responses	786,048	0	800,048
Time Burden (Hours)	555,001	0	563,001
Cost Burden (Dollars)	218,939,600	0	216,021,600

---

Abstract: Section 104 and 4065 of ERISA require plan administrators to file an annual report containing the information described in section 103 of ERISA. The Form 5500 provides a standard format for fulfilling that requirement.

---

Authorizing Statute(s): US Code: 29 USC 1023 Name of Law: Employee Retirement Income Security Act of 1974
  

Citations for New Statutory Requirements: PL: Pub.L. 109 - 280 1103(b) Name of Law: Pension Protection Act of 2006

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
1210-AB12	Not associated with rulemaking	78 FR 13781	03/01/2013

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Annual Information Return/Report	Form 5500 Schedule D, Form 5500 Schedule G, Form 5500 Schedule H, Form 5500-SF, Form 5500 Schedule R, Form 5500, Form 5500 Schedule A, Form 5500 Schedule C, Form 5500 Schedule I, Form 5500 Schedule MB, Form 5500 Schedule SB	Annual Return/Report of Employee Benefit Plan ,   Short Form Annual Return/Report of Small Employee Benefit Plan ,   Insurance Information ,   Service Provider Information ,   DFE/Participating Plan Information ,   Financial Transaction Schedules ,   Financial Information ,   Financial Information--Small Plans ,   Multiemployer Defined Benefit Plans and Certain Money Purchase Plan Actuarial Information ,   Single-Employer Defined Benefit Plan Actuarial Information ,   Retirement Plan Information
Multiple Employer Welfare Arrangements Revisions of Form 5500	Form 5500	Annual Return/Report of Employee Benefit Plans

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	786,048	800,048	0	0	-14,000	0
Annual Time Burden (Hours)	555,001	563,001	0	0	-8,000	0
Annual Cost Burden (Dollars)	218,939,600	216,021,600	0	0	2,918,000	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The number of filings decreased, while the wage rates increased. The net effect of this was a decrease in the number of responses and the time burden, and an increase in the cost burden.

---

Annual Cost to Federal Government: $6,550,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/26/2014

---