Information Collection

Short Format

IC 184199 under ICR 201108-0970-007 · OMB 0970-0060.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0060 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Short Format	Form and Instruction
1 LIHEAP Household Report-Short Form hhsrptin12.xls	Form and Instruction

IC Title:

Short Format

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 34 CFR 45

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	1	LIHEAP Household Report-Short Form	hhsrptin12.xls		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 164

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	164	0	20	144
Annual IC Time Burden (Hours)	164	0	20	144
Annual IC Cost Burden (Dollars)	0	-6,192	0	6,192

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.