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1210-0137 CHIPRA Model Notice 12-14-2022 Clean
1210-0137 CHIPRA Model Notice 12-14-2022 Clean.docx
Model Employer Children's Health Insurance Program Notice
OMB: 1210-0137
OMB.report
DOL/EBSA
OMB 1210-0137
ICR 202211-1210-002
1210-0137 CHIPRA Model Notice 12-14-2022 Clean
( Supporting Statement A )
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1210-0137 can be found here:
2026-01-13 - Extension without change of a currently approved collection
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