Information Collection Request

Form 2678 - Employer/Payer Appointment of Agent

ICR 201409-1545-024 · OMB 1545-0748 · Historical Active

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 2678 Form 2678 - Employer / Payer Appointment of Agent Form and Instruction Modified Available
ombat1.doc Supplementary Document Uploaded 2014-09-09 Available
Supporting Statement.doc Supporting Statement A Uploaded 2014-10-01 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
17366 Form 2678 - Employer / Payer Appointment of Agent Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
03/31/2018 36 Months From Approved 03/31/2015
6,130,000 0 6,130,000
13,731,200 0 13,731,200
0 0 0





Reginfo record details
1
table that charts list of burden
IC Title Form No. Form Name
Form 2678 - Employer / Payer Appointment of Agent 2678 Employer/Payer Appointment of Agent

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 6,130,000 6,130,000 0 0 0 0
Annual Time Burden (Hours) 13,731,200 13,731,200 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No