Ss 1545-2152_2021

SUPPORTING STATEMENT

Internal Revenue Service

OMB Control Number 1545-2152

Health Coverage Tax Credit (HCTC) Reimbursement Request Form

Form 14095

1. CIRCUMSTANCES NECESSITATING COLLECTION OF INFORMATION

As part of the American Recovery and Reinvestment Act (ARRA) changes relating to the Health Coverage Improvement, Section 1899B authorizes that retroactive payments be made to eligible individuals for months occurring prior to the first month for which and advance payment is made on behalf of the eligible individual.

Form 14095 is used by HCTC participants to request reimbursement for health plan premiums paid prior to the commencement of advance payments.

2. USE OF DATA

The information provided by the respondent will be used to determine the amount for the retroactive payment to be made to the participant for monthly premiums paid prior to the commencement of advance payment of the federal tax credit.

3. USE OF IMPROVED INFORMATION TECHNOLOGY TO REDUCE BURDEN

The reimbursement request form will be posted to the Health Coverage Tax Credit (HCTC) website allowing respondents to download the form directly.

4. EFFORTS TO IDENTIFY DUPLICATION

Respondents submitting reimbursement will be asked to specify months during the calendar year for which they are requesting retroactive payment and will be asked to submit supporting documents for each month. Payment history is recorded in HCTC's customer relationship management system to avoid duplication of payments. The information obtained through this collection is unique and is not already available for use or adaptation from another source.

5. METHODS TO MINIMIZE BURDEN ON SMALL BUSINESSES OR OTHER SMALL ENTITIES

There is minimal to no burden on small businesses or entities by this collection due to the inapplicability of the authorizing statute to this type of entity.

6. CONSEQUENCES OF LESS FREQUENT COLLECTION ON FEDERAL PROGRAMS OR POLICY ACTIVITIES

Section 1899B authorizes individuals to request retroactive payments. Without collecting the information request on the reimbursement form, the HCTC will have no way of knowing how much and for what months the individual may request retroactive payments for, and therefore, will hinder the IRS from meeting its mission.

7. SPECIAL CIRCUMSTANCES REQUIRING DATA COLLECTION TO BE INCONSISTENT WITH GUIDELINES IN 5 CFR 1320.5(d)(2)

There are no special circumstances requiring data collection to be inconsistent with guidelines in 5 CFR 1320.5(d)(2).

8. CONSULTATION WITH INDIVIDUALS OUTSIDE OF THE AGENCY ON AVAILABILITY OF DATA, FREQUENCY OF COLLECTION, CLARITY OF INSTRUCTIONS AND FORMS, AND DATA ELEMENTS

In response to the Federal Register Notice (86 FR 68042), dated November 30, 2021, we received no comments during the comment period regarding Form 14095.

9. EXPLANATION OF DECISION TO PROVIDE ANY PAYMENT OR GIFT TO RESPONDENTS

No payment or gift has been provided to any respondents.

10. ASSURANCE OF CONFIDENTIALITY OF RESPONSES

Generally, tax returns and tax return information are confidential as required by 26 USC 6103.

11. JUSTIFICATION OF SENSITIVE QUESTIONS

The reimbursement request form requests limited sensitive information regarding health plan coverage and qualified family members solely for the purpose of processing retroactive payments.

A privacy impact assessment (PIA) has been conducted for information collected under this request as part of the “Health Coverage Tax Credit Program-Closeout Phase (HCTC)” and a Privacy Act System of Records notice (SORN) has been issued for this system under IRS SORN: Treasury/IRS 22.012-Health Coverage Tax Credit Program Records 34.037-IRS Audit Trail and Security Records System; The Department of Treasury PIAs can be found at https://www.irs.gov/uac/Privacy-Impact-Assessments-PIA.

12. ESTIMATED BURDEN OF INFORMATION COLLECTION

It is estimated the reimbursement request form will be used by 3,416 respondents one time annually. The total number of hours estimated for respondents is 2,278 annually.

Authority	Description	# of Respondents	# Responses per Respondent	Annual Responses	Hours per Response	Total Burden
ARRA 1899B	Form 14095	3,416	1	3,416	.67	2,278
Totals		3,416		3,416		2,278

The Privacy Act Notice can be found in the form instructions.

13. ESTIMATED TOTAL ANNUAL COST BURDEN TO RESPONDENTS

To ensure more accuracy and consistency across its information collections, IRS is currently in the process of revisiting the methodology it uses to estimate burden and costs. Once this methodology is complete, IRS will update this information collection to reflect a more precise estimate of burden and costs.

14. ESTIMATED ANNUALIZED COST TO THE FEDERAL GOVERNMENT

To ensure more accuracy and consistency across its information collections, IRS is currently in the process of revisiting the methodology it uses to estimate burden and costs. Once this methodology is complete, IRS will update this information collection to reflect a more precise estimate of burden and costs.

15. REASONS FOR CHANGE IN BURDEN

There are no changes to the form at this time, however the agency has updated the number of responses based on most recent filing data. There has been an estimated increase of 358 responses, resulting in an overall hourly burden increase of 239 hours (2039 to 2278).

	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses	3,416	0	0	358	0	3,058
Annual Time Burden (Hr)	2,278	0	0	239	0	2,039
Annual Cost Burden ($)	0	0	0	0	0	0

16. PLANS FOR TABULATION, STATISTICAL ANALYSIS AND PUBLICATION

There are no plans for tabulation, statistical analysis, and publication.

17. REASONS WHY DISPLAYING THE OMB EXPIRATION DATE IS INAPPROPRIATE

The IRS believes that displaying the OMB expiration date is inappropriate because it could cause confusion by leading taxpayers to believe that the regulations sunset as of the expiration date. Taxpayers are not likely to be aware that the Service intends to request renewal of the OMB approval and obtain a new expiration date before the old one expires.

18. EXCEPTIONS TO THE CERTIFICATION STATEMENT

There are no exceptions to the certification statement.

Note: The following paragraph applies to all of the collections of information in this submission:

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection of information displays a valid OMB control number. Books or records relating to a collection of information must be retained as long as their contents may become material in the administration of any internal revenue law. Generally, tax returns and tax return information are confidential, as required by 26 U.S.C. 6103.

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