Information Collection

Model Employer CHIP Notice (State, Local, Tribal Governmental Burden)

IC 208807 under ICR 201909-1210-008 · OMB 1210-0137.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0137 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CHIP Model Notice.doc	Other-Model Notice
CHIP Model Notice (Spanish).doc	Other-Model Notice Spanish

IC Title:

Model Employer CHIP Notice (State, Local, Tribal Governmental Burden)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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
Other-Model Notice			CHIP Model Notice.doc		Yes	No	Fillable Printable
Other-Model Notice Spanish			CHIP Model Notice (Spanish).doc		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 67,335

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 56 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	13,549,920	232,753	13,317,167
Annual IC Time Burden (Hours)	49,192	-4,299	53,491
Annual IC Cost Burden (Dollars)	1,180,604	-103,171	1,283,775

Documents for IC

table that charts IC Documents
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.