Information Collection

Instrument 5

IC 198422 under ICR 201109-0990-003 · OMB 0990-0382.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0382 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Instrument 5.pdf	Other-Instrument 5

IC Title:

Instrument 5

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

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
Other-Instrument 5			Instrument 5.pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 533

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-533	533
Annual IC Time Burden (Hours)	-373	373
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.