Form 14116 - HCTC - Family Member Eligibility Form

Forms and Documents

Document Name	Status
Form 14116 Form 14116 - HCTC - Family Member Eligibility Form Form	Modified
SS Form 14116 REV.pdf Supporting Statement A	2010-06-18
ombat2.doc Supplementary Document	2009-11-03

IC Document Collections

IC ID	Document Title	Status
191172	Form 14116 - HCTC - Family Member Eligibility Form Form	Modified

ICR Details

OMB Control No: 1545-2163	ICR Reference No: 201006-1545-023
Status: Historical Active	Previous ICR Reference No: 200911-1545-005
Agency/Subagency: TREAS/IRS	Agency Tracking No:
Title: Form 14116 - HCTC - Family Member Eligibility Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/02/2010
	Date Received in OIRA: 06/25/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2013	36 Months From Approved	09/30/2010
Responses	180	0	180
Time Burden (Hours)	30	0	30
Cost Burden (Dollars)	0	0	0

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Abstract: This form will be used by the family members of Health Coverage Tax Credit (HCTC) eligible individuals under circumstances where the original candidate has died or become divorced from the family member. This form allows family member to begin the HCTC registration process by verifying the family member’s eligibility.

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Authorizing Statute(s): PL: Pub.L. 111 - 5 1899E Name of Law: American Recovery and Reinvestment Act of 2009
   US Code: 26 USC 35 Name of Law: Health insurance costs of eligible individuals
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 5873	02/04/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 36473	06/25/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Form 14116 - HCTC - Family Member Eligibility Form	14116	HCTC Family Member Eligibility

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	180	180	0	0	0	0
Annual Time Burden (Hours)	30	30	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $20

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Yes

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/25/2010

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