Information Collection

Active Duty Dental Program Claim Form

IC 203005 under ICR 202603-0720-003 · OMB 0720-0053.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Active Duty Dental Program Claim Form Active Duty Dental Program Claim Form	Form
Active Duty Dental Program Claim Form Active Duty Dental Program Claim Form	Form
Active Duty Dental Program Claim Form ADDP UCCI OCONUS Claim Form.pdf secure.addp-ucci.com/dentist/tools-and-resources/forms	Form
Active Duty Dental Program Claim Form ADDP UCCI OCONUS Claim Form.pdf secure.addp-ucci.com/dentist/tools-and-resources/forms	Form

IC Title:

Agency IC Tracking Number:

0720-0053

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	N/A			https://secure.addp-ucci.com/dentist/tools-and-resources/forms	Yes	Yes	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 105,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 68 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	420,000	0	420,000
Annual IC Time Burden (Hours)	105,000	0	105,000
Annual IC Cost Burden (Dollars)	2,466,450	458,850	2,007,600

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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