Model Employer CHIP Notice (State, Local, Tribal Governmental Burden)

Model Employer Children's Health Insurance Program Notice

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0137 can be found here:

Documents and Forms

Document Name Document Type
chipmodelnotice_7-31-13.doc www.dol.gov/ebsa/chipmodelnotice.doc Other-Model Notice

Information Collection (IC) Details

IC Title:	Model Employer CHIP Notice (State, Local, Tribal Governmental Burden)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Notice			chipmodelnotice_7-31-13.doc	www.dol.gov/ebsa/chipmodelnotice.doc	Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 76,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 38 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	2,222,846	2,222,846
Annual IC Time Burden (Hours)	11,481	11,481
Annual IC Cost Burden (Dollars)	275,637	275,637

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.