Information Collection

COBRA Notices

IC 246194 under ICR 202103-1210-002 · OMB 1210-0167.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Alternative COBRA subsidy notice final clean.docx www.dol.gov/cobra-subsidy	Other-Alternative COBRA subsidy noti
ARP GENERAL NOTICE - final clean 4.6.21.docx www.dol.gov/cobra-subsidy	Other-ARP General Notice
Expiration of the Period of Premium Assistance Notice -final clean.docx www.dol.gov/cobra-subsidy	Other-Expiration of the Period of Pr
Extended Election Period Notice final clean.docx www.dol.gov/cobra-subsidy	Other-Extended Election Period Notic
DOL EBSA COBRA subsidy FAQs final clean.docx www.dol.gov/cobra-subsidy	Other-FAQs
Summary of arp requirements final clean.docx www.dol.gov/cobra-subsidy	Other-Summary of ARP requirements

IC Title:

COBRA Notices

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Alternative COBRA subsidy notice	Alternative COBRA subsidy notice final clean.docx	https://www.dol.gov/cobra-subsidy	Yes	No	Fillable Printable
Other-ARP General Notice	ARP GENERAL NOTICE - final clean 4.6.21.docx	https://www.dol.gov/cobra-subsidy	Yes	No	Fillable Printable
Other-Expiration of the Period of Premium Assistance Notice	Expiration of the Period of Premium Assistance Notice -final clean.docx	https://www.dol.gov/cobra-subsidy	Yes	No	Fillable Printable
Other-Extended Election Period Notice	Extended Election Period Notice final clean.docx	https://www.dol.gov/cobra-subsidy	Yes	No	Fillable Printable
Other-FAQs	DOL EBSA COBRA subsidy FAQs final clean.docx	https://www.dol.gov/cobra-subsidy	Yes	No	Printable Only
Other-Summary of ARP requirements	Summary of arp requirements final clean.docx	https://www.dol.gov/cobra-subsidy	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 726,015

Number of Respondents for Small Entity: 580,660

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	41,455,446	41,455,446
Annual IC Time Burden (Hours)	548,983	548,983
Annual IC Cost Burden (Dollars)	30,599,590	30,599,590

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.