Information Collection

Health Insurance Costs of Eligible Individuals

IC 19545 under ICR 202001-1545-011 · OMB 1545-1875.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-1875 can be found here:

Documents and Forms

Document Name Document Type
Revenue Procedure. 2004-12.pdf RP 2004-12 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Insurance Costs of Eligible Individuals	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 26 CFR 6103

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	51	51
Annual IC Time Burden (Hours)	26	26
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
RP 2004-12	Revenue Procedure. 2004-12.pdf	01/15/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.