Health Insurance Premium Tax Credit

Forms and Documents

Document Name	Status
Form 1095-A Form 1095-A- Health Insurance Marketplace Statement Form	Modified
2017-11-07_SS_1545-2232r.docx Supporting Statement A	2017-11-08

IC Document Collections

IC ID	Document Title	Status
213666	Form 1095-A- Health Insurance Marketplace Statement Form	Modified

ICR Details

OMB Control No: 1545-2232	ICR Reference No: 201711-1545-006
Status: Active	Previous ICR Reference No: 201410-1545-025
Agency/Subagency: TREAS/IRS	Agency Tracking No:
Title: Health Insurance Premium Tax Credit
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/04/2018
	Date Received in OIRA: 12/27/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	36 Months From Approved	06/30/2018
Responses	3,250,000	0	2,000,000
Time Burden (Hours)	16,250	0	11,250
Cost Burden (Dollars)	0	0	0

---

Abstract: This document covers regulations previously approved under 26 CFR 1.36B-5 which relate to the health insurance premium assistance credit enacted by the Patient Protection and Affordable Care Act (PPACA). The regulations provide guidance to individuals who claim the premium assistance credit and exchanges that make qualified health plans available to individuals and employers. The IRS developed Form 1095-A under the authority of ICR section 36B(f)(3) for individuals to compute the amount of premium tax credit and file an accurate tax return.

---

Authorizing Statute(s): US Code: 26 USC 36B Name of Law: Premium assistance credit
   PL: Pub.L. 111 - 148 1411, 1412 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 49267	10/24/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 61368	12/27/2017
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Form 1095-A- Health Insurance Marketplace Statement	1095-A	Health Insurance Marketplace Statement

---

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	3,250,000	2,000,000	0	0	1,250,000	0
Annual Time Burden (Hours)	16,250	11,250	0	0	5,000	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: The agency has updated the number of responses based on it's most recent filing data, resulting in an increase of 1,250,000 responses for a total of 3,250,000 responses (forms) received. This change in responses results in an overall hourly burden increase of 5,000 hours for a total of 16,250 hours.

---

Annual Cost to Federal Government: $0

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 12/27/2017

---