Information Collection

Certification of Non-Contributory TRICARE Supplement Insurance

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

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Information Collection (IC) Details

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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:

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 %

	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.