Information Collection

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

IC 208807 under ICR 201406-1210-002 · OMB 1210-0137.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0137 can be found here:

Documents and Forms

Document Name Document Type
chipmodelnotice 4 28 14 for ROCIS.doc Other-Model Notice
CHIPModelNoticeSP.doc Other-Model Notice Spanish

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Model Employer CHIP Notice (State, Local, Tribal Governmental Burden)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-Model Notice			chipmodelnotice 4 28 14 for ROCIS.doc		Yes	No	Fillable Printable
Other-Model Notice Spanish			CHIPModelNoticeSP.doc		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 76,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 38 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,222,846	2,222,846
Annual IC Time Burden (Hours)	11,481	11,481
Annual IC Cost Burden (Dollars)	275,637	275,637

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.