THE INFORMATION COLLECTED BY THE USE
OF THIS FORM IS NEEDED TO VERIFY AN APPLICANT'S FINANCIAL ACCOUNT
RECORD WITH AN INSTITUTION. IT IS ONLY REQUESTED FROM FINANCIAL
INSTITUTIONS IF THE APPLICANT'S RECORDS ARE INCOMPLETE,
UNAVAILABLE, OR APPEAR TO HAVE BEEN ALTERED, AND IS USED TO
DETERMINE IF THE APPLICANT HAS EXCESS RESOURCES WHICH MAY PRECLUDE
HIM/HER FROM ENTITLEMENT TO CERTAIN TYPES
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.