Form 8453-R - Declaration and Signature for Electronic Filing of Forms 8947 and 8963

Forms and Documents

Document Name	Status
Form 8453-R Form 8453-R - Declaration and Signature for Electronic Filing of Forms 8947 and 8963 Form and Instruction	Modified
SUP STAT (Form 8453-R) 2017.docx Supporting Statement A	2017-03-09

IC Document Collections

IC ID	Document Title	Status
210086	Form 8453-R - Declaration and Signature for Electronic Filing of Forms 8947 and 8963 Form and Instruction	Modified

ICR Details

OMB Control No: 1545-2253	ICR Reference No: 201702-1545-012
Status: Historical Active	Previous ICR Reference No: 201401-1545-018
Agency/Subagency: TREAS/IRS	Agency Tracking No:
Title: Form 8453-R - Declaration and Signature for Electronic Filing of Forms 8947 and 8963
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/16/2017
	Date Received in OIRA: 03/28/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved	06/30/2017
Responses	2,550	0	2,550
Time Burden (Hours)	4,131	0	4,131
Cost Burden (Dollars)	0	0	0

---

Abstract: Use Form 8453-R to authenticate the electronic filing of Form 8947, Report of Branded Prescription Drug Information, and Form 8963, Report of Health Insurance Provider Information.

---

Authorizing Statute(s): PL: Pub.L. 111 - 152 1406 Name of Law: Health Care and Education Reconciliation Act of 2010
   PL: Pub.L. 111 - 148 9010 Name of Law: Patient Protection and Affordable Care Act (PPACA)
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 9010 Name of Law: Patient Protection and Affordable Care Act (PPACA)
PL: Pub.L. 111 - 152 1406 Name of Law: Health Care and Education Reconciliation Act of 2010

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 83332	11/21/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 15419	03/28/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Form 8453-R - Declaration and Signature for Electronic Filing of Forms 8947 and 8963	8453-R	Declaration and Signature for Electronic Filing of Forms 8947 and 8963

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	2,550	2,550	0	0	0	0
Annual Time Burden (Hours)	4,131	4,131	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $150

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/28/2017

---