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Third Party Collection Program (Insurance Information)
Third Party Collection Program (Insurance Information)
OMB: 0704-0323
IC ID: 5378
OMB.report
DOD/DODDEP
OMB 0704-0323
ICR 201003-0704-001
IC 5378
( )
Documents and Forms
Document Name
Document Type
Form DD-2569
Third Party Collection Program (Insurance Information)
Form
DD-2569 Third Party Collection Program/Medical Services Account/
dd2569.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Third Party Collection Program (Insurance Information)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
32 CFR 220
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
DD-2569
Third Party Collection Program/Medical Services Account/Other Health Insurance
dd2569.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Defense and National Security
Subfunction:
Operational Defense
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
3,507,390
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
80 %
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
3,507,390
0
0
700,178
0
2,807,212
Annual IC Time Burden (Hours)
175,370
0
0
35,009
0
140,361
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
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.