Doi

SF-424 Individual(I)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 4040-0005 can be found here:

Documents and Forms

Document Name Document Type
Form 424 DOI Form
424 Individual SF424_Individual-V1 0_SSNMockup2.pdf Form

Information Collection (IC) Details

IC Title:	DOI	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 1320.5 (d)(2)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	424	Individual	SF424_Individual-V1 0_SSNMockup2.pdf		No	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 110	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	220	-6,729	6,949
Annual IC Time Burden (Hours)	92	-2,771	2,863
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.