Information Collection

IDR Entity Certification and IDR Entity Monthly Reporting

IC 248857 under ICR 202202-1210-002 · OMB 1210-0169.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0169 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
7. Tri-dept - IDR certification application (data elements) clean 9.28.21.docx	Other-IDR Certification Application
7. Tri-dept - IDR certification application (data elements) clean 9.28.21.docx	Other-IDR Certification Application
8. Tri-dept - notice of petition for certification denial or revocation clean 9.28.21.docx	Other-Notice of Petition for Denial
8. Tri-dept - notice of petition for certification denial or revocation clean 9.28.21.docx	Other-Notice of Petition for Denial
9. Tri-dept - monthly IDR entity reporting requirements (data elements) clean 9.28.21.docx	Other-Monthly IDR Entity Reporting R
9. Tri-dept - monthly IDR entity reporting requirements (data elements) clean 9.28.21.docx	Other-Monthly IDR Entity Reporting R
CMS-10791- PPDR-SDRE Determination Notice.pdf	Other-SDRE Determination Notice
CMS-10791- PPDR-SDRE Determination Notice.pdf	Other-SDRE Determination Notice
CMS-10791 - Appendix-SDR Entity Certification Data Elements.pdf	Other-SDRE Confirmation of Receipt o
CMS-10791 - Appendix-SDR Entity Certification Data Elements.pdf	Other-SDRE Confirmation of Receipt o
CMS-10791 - PPDR-SDRE Selection Notice.pdf	Other-SDRE Selection Notice
CMS-10791 - PPDR-SDRE Selection Notice.pdf	Other-SDRE Selection Notice
CMS-10791 - Appendix-SDRE Confirmation of Receipt of Settlement Notice.pdf	Other-SDRE Entity Certification Data
CMS-10791 - Appendix-SDRE Confirmation of Receipt of Settlement Notice.pdf	Other-SDRE Entity Certification Data
CMS-10791 - SDRE Declining Eligibility or Need More Information Notice.pdf	Other-SDRE Declining Eligibility or
CMS-10791 - SDRE Declining Eligibility or Need More Information Notice.pdf	Other-SDRE Declining Eligibility or
APPENDIX 6 Certified IDR Enity Written Determination.docx	Other-Certified IDR Entity Written D
APPENDIX 6 Certified IDR Enity Written Determination.docx	Other-Certified IDR Entity Written D

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

IDR Entity Certification and IDR Entity Monthly Reporting

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-IDR Certification Application	7. Tri-dept - IDR certification application (data elements) clean 9.28.21.docx	Yes	Yes	Fillable Printable
Other-Notice of Petition for Denial or Revocation	8. Tri-dept - notice of petition for certification denial or revocation clean 9.28.21.docx	Yes	Yes	Fillable Printable
Other-Monthly IDR Entity Reporting Requirements	9. Tri-dept - monthly IDR entity reporting requirements (data elements) clean 9.28.21.docx	Yes	Yes	Fillable Printable
Other-SDRE Determination Notice	CMS-10791- PPDR-SDRE Determination Notice.pdf	Yes	Yes	Fillable Printable
Other-SDRE Confirmation of Receipt of Settlement Information	CMS-10791 - Appendix-SDR Entity Certification Data Elements.pdf	Yes	Yes	Fillable Printable
Other-SDRE Selection Notice	CMS-10791 - PPDR-SDRE Selection Notice.pdf	Yes	Yes	Fillable Printable
Other-SDRE Entity Certification Data Elements	CMS-10791 - Appendix-SDRE Confirmation of Receipt of Settlement Notice.pdf	Yes	Yes	Fillable Printable
Other-SDRE Declining Eligibility or Need More Information	CMS-10791 - SDRE Declining Eligibility or Need More Information Notice.pdf	Yes	Yes	Fillable Printable
Other-Certified IDR Entity Written Determination	APPENDIX 6 Certified IDR Enity Written Determination.docx	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 13

Number of Respondents for Small Entity: 0

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	Previously Approved
Annual Number of Responses for this IC	85	85
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	22,135	22,135

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.