Information Collection

Systems Changes to Collect Policyholder Surcharges (First Year Only)

IC 227214 under ICR 201706-1505-001 · OMB 1505-0200.

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Information Collection (IC) Details

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IC Title:	Systems Changes to Collect Policyholder Surcharges (First Year Only)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 31 CFR 50

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	80,000	80,000
Annual IC Cost Burden (Dollars)	7,400,000	7,400,000

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