Information Collection Request

Employer/Payer Appointment of Agent (Form 2678)

ICR 202102-1545-010 · OMB 1545-0748 · Received in OIRA

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form 2678 Form 2678 - Employer / Payer Appointment of Agent Form and Instruction Unchanged Repair queued
Supporting Statement 1545-0748.docx Supporting Statement A Uploaded 2021-04-26 Repair queued

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
17366 Form 2678 - Employer / Payer Appointment of Agent Form and Instruction Unchanged

ICR Details

Reginfo record details
table that charts list comparision
  Requested Previously Approved
36 Months From Approved 04/30/2021
6,130,000 6,130,000
13,731,200 13,731,200
0 0





Reginfo record details
1
table that charts list of burden
IC Title Form No. Form Name
Form 2678 - Employer / Payer Appointment of Agent 2678 Employer/Payer Appointment of Agent

table that charts list of burden
  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 6,130,000 6,130,000 0 0 0 0
Annual Time Burden (Hours) 13,731,200 13,731,200 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0


Reginfo record details
  No