Form 8963, Report of Health Insurance Provider Information

REG-118315-12 (FINAL), Health Insurance Providers Fee and Form 8963, Report of Health Insurance Provider Information

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2249 can be found here:

Documents and Forms

Document Name Document Type
Form Form 8963 Form 8963, Report of Health Insurance Provider Information Form
i8963--2016-02-00.pdf Instruction
Form 8963 Report of Health Insurance Provider Information f8963--2016-02-00.pdf Form

Information Collection (IC) Details

IC Title:	Form 8963, Report of Health Insurance Provider Information	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
Form	Form 8963	Report of Health Insurance Provider Information	f8963--2016-02-00.pdf		Yes	Yes	Fillable Fileable
Instruction			i8963--2016-02-00.pdf		Yes	No	Printable Only

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,400	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	17,808	17,808
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.