Form 4423

Information Reporting by Applicable Large Employers on Health Insurance Coverage Offered Under Employer-Sponsored Plans

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form 4423 Form 4423 Form and Instruction
4423 Application for Filing Affordable Care Act (ACA) Informa f4423--2016-03-00.pdf www.IRS.gov Form and Instruction

Information Collection (IC) Details

IC Title:	Form 4423	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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	f4423--2016-03-00.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 %

	Approved	Previously Approved
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

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.