Additional Information to Be Shared with the Initial Payment or Notice of Denial of Payment

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⚠️ Notice: This information collection may be referencing outdated material.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
Additional Information to Be Shared with the Initial Payment or Notice of Denial of Payment.docx Other-Disclosure Requirement

Information Collection (IC) Details

IC Title:	Additional Information to Be Shared with the Initial Payment or Notice of Denial of Payment	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-Disclosure Requirement			Additional Information to Be Shared with the Initial Payment or Notice of Denial of Payment.docx		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 421	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: 95 %

	Approved	Previously Approved
Annual Number of Responses for this IC	127,955	127,955
Annual IC Time Burden (Hours)	21,326	21,326
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.