OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Self-Certification or Notification

IC 205659 under ICR 202407-1210-002 · OMB 1210-0150.

Documents and Forms
Document Name
Document Type
Other-Model Notice
Other-Model Notice
Form
Form
Information Collection (IC) Details

View Information Collection (IC)

Self-Certification or Notification
 
No Modified
 
Voluntary
 
29 CFR 2590.715-2713A 29 CFR 2510.3-16

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Other-Model Notice CMS-10653 Model Notice to HHS_clean.docx Yes Yes Printable Only
Form EBSA Form 700 Eligible Organization Self-Certification EBSA Form 700- Certification.docx https://www.dol.gov/sites/dolgov/files/ebsa/pdf_files/ebsa-form-700.pdf Yes No Printable Only

Health Health Care Services

 

5 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   58 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5 0 0 0 0 5
Annual IC Time Burden (Hours) 4 0 0 0 0 4
Annual IC Cost Burden (Dollars) 4 0 0 2 0 2

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.