SUP STAT (Form 8453-R)_1545-2253_MS (N)

SUPPORTING STATEMENT

Internal Revenue Service

(Form 8453-R) Electronic Filing Declaration for Form 8963

OMB #1545-2253

1. CIRCUMSTANCES NECESSITATING COLLECTION OF INFORMATION

This form was established under Section 9010 of the Patient Protection and Affordable Care Act (PPACA), Public Law No. 111-148 (124 Stat. 119 (2010)), as amended by section 10905 of PPACA, and as further amended by section 1406 of the Health Care and Education Reconciliation Act of 2010, Public Law 111-152 (124 Stat. 1029 (2010), which requires any covered entity engaged in the business of providing health insurance related to United States health risks must annually report its net premiums. The purpose of the form is to authenticate the electronic filing of Form 8963, Report of Health Insurance Provider Information.

2. USE OF DATA

The IRS will use Form 8453-R to authenticate the electronic filing of Form 8963.

3. USE OF IMPROVED INFORMATION TECHNOLOGY TO REDUCE BURDEN

The agency has made Form 8453-R available and is accepting

Form 8453-R electronically.

4. EFFORTS TO IDENTIFY DUPLICATION

The information obtained through this collection is unique and is

not already available for use or adaptation from another source.

5. METHODS TO MINIMIZE BURDEN ON SMALL BUSINESSES OR OTHER SMALL

ENTITIES

The collection of information requirement will not have a

significant economic impact on a substantial number of small

entities.

6. CONSEQUENCES OF LESS FREQUENT COLLECTION ON FEDERAL PROGRAMS OR

POLICY ACTIVITIES

If the Internal Revenue Service (IRS) did not collect this

information, the IRS will not be able to authenticate the

electronic filing of Form 8963 and would not be able meet its

mission.

7. SPECIAL CIRCUMSTANCES REQUIRING DATA COLLECTION TO BE INCONSISTENT

WITH GUIDELINES IN 5 CFR 1320.5(d)(2)

There are no special circumstances requiring data collection to be

inconsistent with Guidelines in 5 CFR 1320.5(d)(2).

8. CONSULTATION WITH INDIVIDUALS OUTSIDE OF THE AGENCY ON AVAILABILITY

OF DATA, FREQUENCY OF COLLECTION, CLARITY OF INSTRUCTIONS AND

FORMS, AND DATA ELEMENTS

In response to the Federal Register notice dated January 24, 2020

(85 FR 4355), we received no comments during the comment period

regarding Form 8453-R.

9. EXPLANATION OF DECISION TO PROVIDE ANY PAYMENT OR GIFT TO

RESPONDENTS

No payment or gift will be provided to any respondents.

10. ASSURANCE OF CONFIDENTIALITY OF RESPONSES

Generally, tax returns and tax return information are confidential

as required by 26 USC 6103.

11. JUSTIFICATION OF SENSITIVE QUESTIONS

No personally identifiable information (PII) is collected.

12. ESTIMATED BURDEN OF INFORMATION COLLECTION

The burden estimate is as follows:

Authority	Description	# of Respondants	# Responses per Respondant	Annual Responses	Hours per Response	Total Burden
Public Law 111-152	Form 8453-R, Electronic Filing Declaration for Form 8963	2,550	1	2,550	1.62	4,131

13. ESTIMATED TOTAL ANNUAL COST BURDEN TO RESPONDENTS

To ensure more accuracy and consistency across its information

collections, IRS is currently in the process of revising the

methodology it uses to estimate burden and costs. Once this

methodology is complete, IRS will update this information

collection to reflect a more precise estimate of burden and costs.

14. ANNUALIZED COST TO THE FEDERAL GOVERNMENT

The Federal government cost estimate is based on a model that considers

the following three cost factors for each information product:

aggregate labor costs for development, including annualized start up expenses, operating and maintenance expenses, and distribution of the product that collects the information.

The government computes cost using a multi-step process. First, the government creates a weighted factor for the level of effort to create each information collection product based on variables such as; complexity, number of pages, type of product and frequency of revision. Second, the total costs associated with developing the product such as labor cost, and operating expenses associated with the downstream impact such as support functions, are added together to obtain the aggregated total cost. Then, the aggregated total cost and factor are multiplied together to obtain the aggregated cost per product. Lastly, the aggregated cost per product is added to the cost of shipping and printing each product to IRS offices, National Distribution Center, libraries and other outlets. The result is the Government cost estimate per product.

The government cost estimate for this collection is summarized in the table below.

Product	Aggregate Cost per Product (factor applied)		Printing and Distribution		Government Cost Estimate per Product
Form 8453-R	10,936	+		=	10,936
Instructions
Grand Total	10,936				10,936
Table costs are based on 2018 actuals obtained from IRS Chief Financial Office and Media and Publications
* New product costs will be included in the next collection update.

15. REASONS FOR CHANGE IN BURDEN

There is no change to the paperwork burden previously approved by OMB. IRS is making this submission for renewal purposes.

16. PLANS FOR TABULATION, STATISTICAL ANALYSIS AND PUBLICATION

There are no plans for tabulation, statistical analysis and

publication.

17. REASONS WHY DISPLAYING THE OMB EXPIRATION DATE IS INAPPROPRIATE

IRS believes that displaying the OMB expiration date is inappropriate because it could cause confusion by leading taxpayers to believe that the form sunsets as of the expiration date. Taxpayers are not likely to be aware that the IRS intends to request renewal of the OMB approval and obtain a new expiration date before the old one expires.

18. EXCEPTIONS TO THE CERTIFICATION STATEMENT

There are no exceptions to the certification statement for this

collection.

Note: The following paragraph applies to all of the collections

of information in this submission:

An agency may not conduct or sponsor, and a person is not

required to respond to, a collection of information unless

the collection of information displays a valid OMB control

number. Books or records relating to a collection of

information must be retained as long as their contents may

become material in the administration of any internal

revenue law. Generally, tax returns and tax return

information are confidential, as required by 26 U.S.C. 6103.