Form 13560 - Health Plan Administrator (HPA) Return of Funds

ICR 202010-1545-008

OMB: 1545-1891

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2020-12-18
IC Document Collections
ICR Details
1545-1891 202010-1545-008
Received in OIRA 201704-1545-033
TREAS/IRS
Form 13560 - Health Plan Administrator (HPA) Return of Funds
Extension without change of a currently approved collection   No
Regular 12/29/2020
  Requested Previously Approved
36 Months From Approved 01/31/2021
200 200
50 50
0 0

Form 13560 is completed by Health Plan Administrators (HPAs) and accompanies a return of funds in order to ensure proper handling. This form serves as supporting documentation for any funds returned by an HPA and clarifies where the payment should be applied and why it is being sent.

US Code: 26 USC 35 Name of Law: Health Insurance Costs of Eligible Individuals
   US Code: 26 USC 7527 Name of Law: Advance Payment of Credit for Health Insurance Costs of Eligible Individuals
   PL: Pub.L. 107 - 210 151 Name of Law: Credit for Health Insurance Costs of Eligible Individuals
  
None

Not associated with rulemaking

  85 FR 57934 09/16/2020
85 FR 84468 12/28/2020
No

1
IC Title Form No. Form Name
Form 13560 - HCTC Health Plan Administrator (HPA) Return of Funds Form 13560 Health Plan Administrator (HPA) Return of Funds

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 200 200 0 0 0 0
Annual Time Burden (Hours) 50 50 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$100
No
    Yes
    Yes
No
No
No
No
Michael Gonzales 859 669-5549

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
12/29/2020


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