Information Collection

Recoupment Provisions

IC 227208 under ICR 202311-1505-002 · OMB 1505-0200.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form TRIP 04A Direct Written Premium and Monthly Surcharge Calculation Recoupment Provisions	Form
Form TRIP 04B Direct Written Premium and End of Year Calcuation Recoupment Provisions	Form
TRIP Form 04A Monthly Recoupment Calculation Instructions.doc tripclaims.treas.gov/TRIP/	Instruction
TRIP Form 04A Monthly Recoupment Calculation Instructions.doc tripclaims.treas.gov/TRIP/	Instruction
TRIP Form 04B End of Year Recoupment Calculation Instructions.doc	Instruction
TRIP Form 04B End of Year Recoupment Calculation Instructions.doc	Instruction
TRIP 04A Direct Written Premium and Monthly Surcharge Calculation TRIP Form 04A Monthly Recoupment Calculation.doc tripclaims.treas.gov/TRIP/	Form
TRIP 04A Direct Written Premium and Monthly Surcharge Calculation TRIP Form 04A Monthly Recoupment Calculation.doc tripclaims.treas.gov/TRIP/	Form
TRIP 04B Direct Written Premium and End of Year Calcuation TRIP Form 04B End of Year Recoupment Calculation.doc tripclaims.treas.gov/TRIP/	Form
TRIP 04B Direct Written Premium and End of Year Calcuation TRIP Form 04B End of Year Recoupment Calculation.doc tripclaims.treas.gov/TRIP/	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: 31 CFR 50

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction		https://tripclaims.treas.gov/TRIP/	Yes	Yes	Fillable Fileable
Form	TRIP 04A	https://tripclaims.treas.gov/TRIP/	Yes	Yes	Fillable Fileable
Instruction		Direct Written Premium and Monthly Surcharge Calcu	Yes	Yes	Fillable Fileable
Form	TRIP 04B	https://tripclaims.treas.gov/TRIP/	Yes	Yes	Fillable Fileable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,250

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	27,000	3,000	24,000
Annual IC Time Burden (Hours)	135,000	15,000	120,000
Annual IC Cost Burden (Dollars)	0	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.

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