Information Collection

FORM 5434, Application for Enrollment; and Form 5434-A, Application for Renewal of Enrollment

IC 17572 under ICR 200312-1545-001 · OMB 1545-0951.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-0951 can be found here:

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Information Collection (IC) Details

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IC Title:	FORM 5434, Application for Enrollment; and Form 5434-A, Application for Renewal of Enrollment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	5434				No	No
Form	5434-A				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	3,800	3,800
Annual IC Cost Burden (Dollars)	0	0

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