Information Collection

Active Duty Dental Program Claim Form

IC 203005 under ICR 202301-0720-002 · OMB 0720-0053.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0053 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form 5579 Active Duty Dental Program Claim Form	Form
Form 5579 Active Duty Dental Program Claim Form 0720-0053_ADDP-Claim-Form-fillable_6.27.2019.pdf secure.addp-ucci.com/dwaddw/adsm/article.xhtml?content=claims-adsm	Form
Form 5579 Active Duty Dental Program Claim Form 0720-0053_ADDP-Claim-Form-fillable_6.27.2019.pdf secure.addp-ucci.com/dwaddw/adsm/article.xhtml?content=claims-adsm	Form

IC Title:

Active Duty Dental Program Claim Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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
Form	Form 5579	Active Duty Dental Program Claim Form	0720-0053_ADDP-Claim-Form-fillable_6.27.2019.pdf	https://secure.addp-ucci.com/dwaddw/adsm/article.xhtml?content=claims-adsm	Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 105,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 68 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	420,000	120,000	300,000
Annual IC Time Burden (Hours)	105,000	30,000	75,000
Annual IC Cost Burden (Dollars)	2,007,600	573,600	1,434,000

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.