Information Collection

Healthy Incentives Pilot (HIP)

IC 191258 under ICR 201203-0584-001 · OMB 0584-0512.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0512 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SF 424 Healthy Incentives Pilot (HIP)	Form and Instruction
SF 424 APPLICATION FOR FEDERAL ASSISTANCE 2008 SF424.pdf www.grants.gov	Form and Instruction
SF424a BUDGET INFORMATION - Non-Construction Programs 2008 SF424a.pdf www.grants.gov	Form and Instruction
SF424b ASSURANCES - NON-CONSTRUCTION PROGRAMS 2008 SF424b.pdf www.grants.gov	Form and Instruction
SF LLL DISCLOSURE OF LOBBYING ACTIVITIES 2008 SF lobbying.pdf www.grants.gov	Form and Instruction
SF 425 Federal Financial Report SF-425 FFR.pdf www.grants.gov	Form and Instruction
HIP -OMB Justification for burden hours revised 12-2-09.doc Supporting Statement Justification for HIP	IC Document
HIP RFA 11 05 09.doc Request for Application Packet (RFA)	IC Document
HIP Memo.doc HIP Memo	IC Document

IC Title:

Healthy Incentives Pilot (HIP)

Agency IC Tracking Number:

IC Status: Unchanged

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
Form and Instruction	SF 424	APPLICATION FOR FEDERAL ASSISTANCE	2008 SF424.pdf	www.grants.gov	Yes	Yes	Fillable Fileable Signable
Form and Instruction	SF424a	BUDGET INFORMATION - Non-Construction Programs	2008 SF424a.pdf	www.grants.gov	Yes	Yes	Fillable Fileable Signable
Form and Instruction	SF424b	ASSURANCES - NON-CONSTRUCTION PROGRAMS	2008 SF424b.pdf	www.grants.gov	Yes	Yes	Fillable Fileable Signable
Form and Instruction	SF LLL	DISCLOSURE OF LOBBYING ACTIVITIES	2008 SF lobbying.pdf	www.grants.gov	Yes	Yes	Fillable Fileable Signable
Form and Instruction	SF 425	Federal Financial Report	SF-425 FFR.pdf	www.grants.gov	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3

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
	Requested	Previously Approved
Annual Number of Responses for this IC	3	3
Annual IC Time Burden (Hours)	480	480
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement Justification for HIP	HIP -OMB Justification for burden hours revised 12-2-09.doc	12/02/2009
Request for Application Packet (RFA)	HIP RFA 11 05 09.doc	11/12/2009
HIP Memo	HIP Memo.doc	11/12/2009

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