View Information Collection (IC)
Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Third Party Collection Program (Insurance Information)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
32 CFR 220
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
DD Form 2569
Third Party Collection Program/Medical Services Account/Other Health Insurance
dd2569 20160616 draft.PDF
Yes
Yes
Fillable Fileable Signable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Defense and National Security
Subfunction:
Operational Defense
Privacy Act System of Records
Title:
DHA 12 Third Pary Collection System
FR Citation:
78 FR 69076
Number of Respondents:
3,900,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
20 %
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
5,850,000
0
2,913,095
0
0
2,936,905
Annual IC Time Burden (Hours)
390,000
0
243,155
0
0
146,845
Annual IC Cost Burden (Dollars)
9,956,700
0
9,956,700
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.