Information Collection

Health Insurance Costs of Eligible Individuals

IC 19545 under ICR 202001-1545-011 · OMB 1545-1875.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-1875 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Revenue Procedure. 2004-12.pdf RP 2004-12	IC Document

IC Title:

Health Insurance Costs of Eligible Individuals

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 26 CFR 6103

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: General Government

Subfunction: Taxation Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 51

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
RP 2004-12	Revenue Procedure. 2004-12.pdf	01/15/2020

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