Application For Self-insurance And Financial Statement

APPLICATION FOR SELF-INSURANCE AND FINANCIAL STATEMENT

OMB: 1215-0018

IC ID: 121829

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Information Collection (IC) Details

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APPLICATION FOR SELF-INSURANCE AND FINANCIAL STATEMENT
 
No Migrated
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form LS-271 No No
Form LS-271A No No


    

100 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 100 0 0 0 0 100
Annual IC Time Burden (Hours) 150 0 0 50 0 100
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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