Information Collection

Self-Certification or Notification to HHS

IC 256647 under ICR 202210-1545-017 · OMB 1545-2307.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

Self-Certification or Notification to HHS

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 26 CFR 26 CFR 54.9815-2713(a)(1)(iv)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	2	2
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	1	1

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.