Information Collection

Attachment 5. Annual Aggregate Data on Medically Ineligible Clients Form

IC 179137 under ICR 200703-0920-006 · OMB 0920-0745.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0745 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Annual Aggregate Data on Medically Ineligible Clients Form Attachment 5. Annual Aggregate Data on Medically Ineligible Clients Form	Form and Instruction
Annual Aggregate Data on Medically Ineligible Clients Fo 0920-05CJ ATTACHMENT 5 Aggregate Medically Ineligible Form.doc	Form and Instruction

IC Title:

Attachment 5. Annual Aggregate Data on Medically Ineligible Clients Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	None				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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