Information Collection

Acknowledgment Card

IC 193114 under ICR 201006-0917-001 · OMB 0917-0006.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0917-0006 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form IHS-815 Acknowledgment Card	Form
IHS-815 Acknowledgment Card IHS-815 and 816 Change of Address.pdf	Form

IC Title:

Acknowledgment Card

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 2 CFR 3506

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	IHS-815	Acknowledgment Card	IHS-815 and 816 Change of Address.pdf		No	No	Paper Only

Line of Business: Education

Subfunction: Higher Education

Privacy Act System of Records

Title: IHS Scholarship Program

FR Citation: 72 FR 5446

Number of Respondents: 1,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,500	1,500
Annual IC Time Burden (Hours)	50	50
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.