Information Collection

Application for Digital-to-Analog Converter Box Coupons for Nursing Home Residents

IC 184582 under ICR 200808-0660-003 · OMB 0660-0027.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0660-0027 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Application for Digital-to-Analog Converter Box Coupons for Nursing Home Residents	Form and Instruction
Application for Converter Box Coupons for Nursing Home R 0660.Draft Nursing Home Coupon Application.Rev.090908.doc	Form and Instruction

IC Title:

Application for Digital-to-Analog Converter Box Coupons for Nursing Home Residents

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	Application for Converter Box Coupons for Nursing Home Residents	0660.Draft Nursing Home Coupon Application.Rev.090908.doc		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 414,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	414,000	414,000
Annual IC Time Burden (Hours)	138,000	138,000
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.