View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Model Employer CHIP Notice (State, Local, Tribal Governmental 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			model-notice.docx	https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/chipra/model-notice.doc	Yes	No	Fillable Printable
Other-Model Notice Spanish			model-notice-spanish.docx	https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/chipra/model-notice-spanish.doc	Yes	No	Fillable Printable

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: 70,959	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 58 %

	Requested	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	9,243,991	0	0	-6,011,948	0	15,255,939
Annual IC Time Burden (Hours)	32,123	0	0	-21,019	0	53,142
Annual IC Cost Burden (Dollars)	770,949	0	0	-504,448	0	1,275,397

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.