Information Collection

Request of Extension of Time Periods for Extenuating Circumstances

IC 249679 under ICR 202302-0938-001CF · 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⚠️ Notice: This information collection may be referencing outdated material.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
13. Appendix-13 Request for Extension Notice.docx	Other-Request of Extension of Time P
CMS-10791 - Appendix 13 Request for Extension Notice.pdf	Other-Request for Extension Notice

IC Title:

Request of Extension of Time Periods for Extenuating Circumstances

Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590

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
Other-Request of Extension of Time Periods for Extenuating Circumstances			13. Appendix-13 Request for Extension Notice.docx		Yes	Yes	Fillable Printable
Other-Request for Extension Notice			CMS-10791 - Appendix 13 Request for Extension Notice.pdf		Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

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	1	1
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

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.