Information Collection

De Novo Application

IC 19789 under ICR 200102-1550-002 · OMB 1550-0005.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1550-0005 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	De Novo Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	FORM-138-F	No	No
Form	FORM-138	No	No
Form	FORM-138-E	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20	-22	42
Annual IC Time Burden (Hours)	2,700	-3,432	6,132
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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