Information Collection

Participant Notification of Individual Coverage HRA of Cancelled or Discontinued Coverage

IC 253233 under ICR 202503-1210-003 · OMB 1210-0160.

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Information Collection (IC) Details

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IC Title:	Participant Notification of Individual Coverage HRA of Cancelled or Discontinued Coverage	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590.702-2

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,630	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,630	-3,954	11,584
Annual IC Time Burden (Hours)	636	-329	965
Annual IC Cost Burden (Dollars)	0	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.