Request of Extension of Time Periods for Extenuating Circumstances

No Surprises Act: IDR Process

Documents and Forms

Document Name Document Type
13. Appendix-13 Request for Extension Notice.docx Other-Request of Extension of Time P
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
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: Modified

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: 5	Number of Respondents for Small Entity: 4

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

Percentage of Respondents Reporting Electronically: 95 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5	-20	25
Annual IC Time Burden (Hours)	1	-5	6
Annual IC Cost Burden (Dollars)	0	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.