Information Collection

IDR Entity Certification and IDR Entity Monthly Reporting

IC 249678 under ICR 202606-0938-001CF · OMB 1210-0169.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0169 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
7. Tri-dept - IDR certification application (data elements) clean 9.28.21.docx	Other-IDR Certification Application
8. Tri-dept - notice of petition for certification denial or revocation clean 9.28.21.docx	Other-Notice of Petition for Denial
9. Tri-dept - monthly IDR entity reporting requirements (data elements) clean 9.28.21.docx	Other-Monthly IDR Entity Reporting R
APPENDIX 6 - IDRE Written Payment Determination FINAL CHANGE 2.23.23.docx	Other-Certified IDR Entity Written D
8. PPDR SDRE Determination Notice.docx	Other-SDRE Determination Notice
Appendix 12- Standard Notice, Selected Dispute Resolution (SDR) Entity Notification.pdf	Other-SDRE Confirmation of Receipt o
CMS-10791-9.-PPDR-SDRE-Selection-Notice.pdf	Other-SDRE Selection Notice
CMS-10791-5.-HHS-Appendix-SDR-Entity-Certification-Data-Elements_508c.pdf	Other-SDRE Entity Certification Data
CMS-10791-3.-SDRE-Declining-Eligibility-or-Need-More-Information-Notice.pdf	Other-SDRE Declining Eligibility or

IC Title:

IDR Entity Certification and IDR Entity Monthly Reporting

Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590

Information Collection Instruments:

table that charts list of instruments
Document Type	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-IDR Certification Application	Yes	Yes	Fillable Printable
Other-Notice of Petition for Denial or Revocation	Yes	Yes	Fillable Printable
Other-Monthly IDR Entity Reporting Requirements	Yes	Yes	Fillable Printable
Other-Certified IDR Entity Written Determination	Yes	Yes	Fillable Printable
Other-SDRE Determination Notice	Yes	Yes	Fillable Printable
Other-SDRE Confirmation of Receipt of Settlement Information	Yes	Yes	Fillable Printable
Other-SDRE Selection Notice	Yes	Yes	Fillable Printable
Other-SDRE Entity Certification Data Elements	Yes	Yes	Fillable Printable
Other-SDRE Declining Eligibility or Need More Information	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1	0	1
Annual IC Time Burden (Hours)	0	0	0
Annual IC Cost Burden (Dollars)	230	25	205

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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].