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Certificate for Health Care Benefits
Certificate for Health Care Benefits
OMB: 1115-0226
IC ID: 12210
OMB.report
DOJ/INS
OMB 1115-0226
ICR 199905-1115-007
IC 12210
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1115-0226 can be found here:
2002-07-29 - Extension without change of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Certificate for Health Care Benefits
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Migrated
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
7,000
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
14,000
0
0
0
0
14,000
Annual IC Time Burden (Hours)
25,620
0
0
0
0
25,620
Annual IC Cost Burden (Dollars)
2,100,000
0
0
0
0
2,100,000
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.