Information Collection

Form 14116 - HCTC - Family Member Eligibility Form

IC 191172 under ICR 201006-1545-023 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Form 14116 - HCTC - Family Member Eligibility Form Form
14116 HCTC Family Member Eligibility Form 14116.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Form 14116 - HCTC - Family Member Eligibility Form	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
Form	14116	HCTC Family Member Eligibility	Form 14116.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	Previously Approved
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.