View Information Collection (IC)

View Information Collection (IC)

IC Title:	Model Employer CHIP Notice (Private Sector Burden)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Model Notice			chipmodelnotice 7-31-13.doc	http://www.dol.gov/ebsa/chipmodelnotice.doc	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,961,000	Number of Respondents for Small Entity: 38

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

Percentage of Respondents Reporting Electronically: 38 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	174,347,154	0	0	-29,447,846	0	203,795,000
Annual IC Time Burden (Hours)	900,519	0	0	-152,481	0	1,053,000
Annual IC Cost Burden (Dollars)	21,619,363	0	0	-3,651,637	0	25,271,000

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.