Certification Statement

Coverage of Certain Preventive Services Under the Affordable Care Act (REG-120391-10 (NPRM))

Documents and Forms

Document Name Document Type
Certification_2-8-13[2].docx Other-Certification Statement

Information Collection (IC) Details

IC Title:	Certification Statement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 26 CFR 54.9815-2713A 26 CFR 54.9815-2713

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Certification Statement			Certification_2-8-13[2].docx		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Taxation Management

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 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	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.