Information Collection

State Agency Ticket Assignment Form Ticket to Work and Self Sufficiency Program

IC 9672 under ICR 200506-0960-005 · OMB 0960-0641.

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Information Collection (IC) Details

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IC Title:	State Agency Ticket Assignment Form Ticket to Work and Self Sufficiency Program	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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-1365				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 82	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	25,174	-6,318	31,492
Annual IC Time Burden (Hours)	1,259	-4,656	5,915
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.