Information Collection

93.671

IC 179686 under ICR 200904-0970-004 · OMB 0970-0139.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0139 can be found here:

Documents and Forms

Document Name Document Type
93.671.mht Other-93.671

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	93.671	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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
Other-93.671			93.671.mht		No	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 325	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	325	325
Annual IC Time Burden (Hours)	13,000	13,000
Annual IC Cost Burden (Dollars)	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.