Information Collection

State Sample Application

IC 200987 under ICR 201111-1860-001 · OMB 1860-0509.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1860-0509 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
State Sample Application	Form
Att_SampleStateApplication.doc	Form
Att_SampleStateScoringRubric 2 6 12.docx Sample State Scoring Rubric	IC Document

IC Title:

State Sample Application

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	N/A	Att_SampleStateApplication.doc		Yes	Yes	Fillable Fileable

Line of Business: Education

Subfunction: Elementary, Secondary, and Vocational Education

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 58

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	58	58
Annual IC Time Burden (Hours)	1,450	1,450
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Sample State Scoring Rubric	Att_SampleStateScoringRubric 2 6 12.docx	02/16/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.