Information Collection

Certification of Non-Contributory TRICARE Supplement Insurance

IC 191500 under ICR 201706-0720-001 · OMB 0720-0044.

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IC Title:

Certification of Non-Contributory TRICARE Supplement Insurance

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 199

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

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	8,750	8,750

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.