Request of Extension of Time Periods for Extenuating Circumstances

No Surprises Act: IDR Process

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0169 can be found here:

Documents and Forms

Document Name Document Type
13. Appendix-13 Request for Extension Notice.docx Other-Request of Extension of Time P
CMS-10791 - Appendix 13 Request for Extension Notice.pdf Other-Request for Extension Notice

Information Collection (IC) Details

IC Title:	Request of Extension of Time Periods for Extenuating Circumstances	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2590

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Request of Extension of Time Periods for Extenuating Circumstances			13. Appendix-13 Request for Extension Notice.docx		Yes	Yes	Fillable Printable
Other-Request for Extension Notice			CMS-10791 - Appendix 13 Request for Extension Notice.pdf		Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25	Number of Respondents for Small Entity: 22

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Previously Approved
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	6	6
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.