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.