Information Collection

Form 4423

IC 214083 under ICR 201411-1545-073 · OMB 1545-2251.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2251 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4423 Form 4423	Form and Instruction
4423 Application for Filing Affordable Care Act (ACA) Informa Form 4423_draft.pdf www.IRS.gov	Form and Instruction

IC Title:

Form 4423

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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 and Instruction	4423	Application for Filing Affordable Care Act (ACA) Information Returns	Form 4423_draft.pdf	www.IRS.gov	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6	6
Annual IC Time Burden (Hours)	2	2
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.