Information Collection

HCTC - Family Member Eligibility Form (Form 14116)

IC 191172 under ICR 200911-1545-005 · OMB 1545-2163.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-2163 can be found here:

Documents and Forms

Document Name Document Type
Form 14116 HCTC - Family Member Eligibility Form (Form 14116) Form
14116 Family Member Eligibility Form DRAFT-Form 14116 120909.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HCTC - Family Member Eligibility Form (Form 14116)	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	14116	Family Member Eligibility Form	DRAFT-Form 14116 120909.pdf		No		Paper Only

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 180	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	180	180
Annual IC Time Burden (Hours)	30	30
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.