Information Collection

Financial Disclosure Form

IC 190377 under ICR 200908-0925-003 · OMB 0925-0613.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0613 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Financial Disclosure Form Financial Disclosure Form	Form and Instruction
3 Financial Disclosure Form Attachment 3_Financial Disclosure_Final_05-09.doc	Form and Instruction

IC Title:

Financial Disclosure 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	3				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17,128

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	17,128	17,128
Annual IC Time Burden (Hours)	1,427	1,427
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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