e2569 Module

Third Party Collection Program (Insurance Information)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0055 can be found here:

Documents and Forms

Document Name Document Type
e2569 Module_2022.pdf Other-Screenshots
e2569 Module_2022.pdf Other-Screenshots

Information Collection (IC) Details

IC Title:	e2569 Module	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screenshots			e2569 Module_2022.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,546,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,319,000	2,319,000
Annual IC Time Burden (Hours)	154,600	154,600
Annual IC Cost Burden (Dollars)	4,882,268	4,882,268

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.