View Information Collection (IC)

View Information Collection (IC)

IC Title:	Form 8963, Report of Health Insurance Provider Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form	8963	Report of Health Insurance Provider Information	Form 8963.pdf		Yes	Yes	Fillable Fileable
Instruction			Instr for Form 8963.pdf		Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,400	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	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	2,400	2,400	0	0	0	0
Annual IC Time Burden (Hours)	17,808	17,808	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	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.