Information Collection

Domestic Assurance

IC 237701 under ICR 202506-0925-002 · OMB 0925-0765.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Domestic Assurance	Form and Instruction
Form 1 Domestic Assurance Domestic Assurance	Form and Instruction
1 Domestic Assurance Domestic Assurance.docx	Form and Instruction
1 Domestic Assurance Domestic Assurance.docx	Form and Instruction

IC Title:

Domestic Assurance

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

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 and Instruction	1				Yes	Yes	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 235

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	Previously Approved
Annual Number of Responses for this IC	235	235
Annual IC Time Burden (Hours)	7,050	7,050
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.

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