TRICARE Retiree Dental Program Enrollment Appication

ICR 201207-0720-003

OMB: 0720-0015

Federal Form Document

Forms and Documents
IC Document Collections
IC ID
Document
Title
Status
5586 Modified
ICR Details
0720-0015 201207-0720-003
Historical Active 200708-0720-003
DOD/DODOASHA
TRICARE Retiree Dental Program Enrollment Appication
Reinstatement with change of a previously approved collection   No
Regular
Approved with change 08/27/2012
Retrieve Notice of Action (NOA) 07/05/2012
Approved consistent with the following terms of clearance: the DoD shall take care in future submissions to submit requests for extensions in a timely manner in order to avoid violating the Paperwork Reduction Act.
  Inventory as of this Action Requested Previously Approved
08/31/2015 36 Months From Approved
64,000 0 0
16,000 0 0
0 0 0

This information is completed by Uniformed Service members entitled to retired pay and their eligible family members who are seeking enrollment in the TRICARE Retiree Dental Program (TRDP). The information is necessary to enable the DoD-contracted third party administrator of the program to identify the program's applicants, determine their eligibiity for TRDP enrollment, establish the premium payment amount, and verify by the applicant's signature that the applicant understands the benefits and rules of the program.

US Code: 10 USC 1076c Name of Law: null
  
None

Not associated with rulemaking

  75 FR 60418 09/30/2010
77 FR 25710 05/01/2012
No

1
IC Title Form No. Form Name
TRICARE Retiree Dental Program Enrollment Appication Delta Dental Form TRICARE Retiree Dental Program Enrollment Application

  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 64,000 0 0 0 -7,332 71,332
Annual Time Burden (Hours) 16,000 0 0 0 -1,833 17,833
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
Decrease in respondents due to a miscalculation. The form has an updated Privacy Act Statement, an updated Agency Disclosure Notice, and reference to Discover as a payment method.

$0
No
No
No
No
No
Uncollected
Patricia Toppings 703 696-5284 PLToppings@whs.mil

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
07/05/2012


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