Information Collection

Third Party Collection Program (Insurance Information)

IC 5378 under ICR 202305-0720-001 · OMB 0720-0055.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD Form 2569 Third Party Collection Program (Insurance Information)	Form
DD Form 2569 Third Party Collection Program/Medical Services Account/ DD2569 draft_2022.pdf	Form
DD Form 2569 Third Party Collection Program/Medical Services Account/ DD2569 draft_2022.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 32 CFR 220

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	DD Form 2569	Third Party Collection Program/Medical Services Account/Other Health Insurance	DD2569 draft_2022.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title: DHA 12 Third Pary Collection System

FR Citation: 78 FR 69076

Number of Respondents: 2,142,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,213,000	-265,500	3,478,500
Annual IC Time Burden (Hours)	214,200	-17,700	231,900
Annual IC Cost Burden (Dollars)	7,100,730	665,505	6,435,225

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.