Information Collection

Financial Assistance & Social Services Application

IC 11443 under ICR 200911-1076-001 · OMB 1076-0017.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1076-0017 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5-6601 Financial Assistance & Social Services Application	Form and Instruction
5-6601 Application for Financial Assistance and Social Services Application for Financial Assistance and Social Services FINAL3.docx www.bia.gov/WhoWeAre/BIA/OIS/SocialServices/index.htm	Form and Instruction

IC Title:

Financial Assistance & Social Services Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 25 CFR 20.300

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	5-6601	Application for Financial Assistance and Social Services	Application for Financial Assistance and Social Services FINAL3.docx	http://www.bia.gov/WhoWeAre/BIA/OIS/SocialServices/index.htm	Yes	No	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: BIA-8, Indian Social Services Case Files

FR Citation: 55 FR 34085

Number of Respondents: 240,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 40 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	240,000	40,000	200,000
Annual IC Time Burden (Hours)	120,000	20,000	100,000
Annual IC Cost Burden (Dollars)	0	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.