Information Collection

Request for Coverage Determination

IC 236023 under ICR 202607-1212-004 · OMB 1212-0072.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form 1 Request for Coverage Determination Request for Coverage Determination	Form
Coverage Determination Instructions 2025.02.pdf	Instruction
Form 1 Request for Coverage Determination Coverage Determination Form 2025.04.pdf	Form

IC Title:

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	Form 1				Yes	Yes	Fillable Fileable Signable
Instruction					Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 295

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	295	295
Annual IC Time Burden (Hours)	443	443
Annual IC Cost Burden (Dollars)	88,500	88,500

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].