Information Collection

Annual Certification - Qualified Nonprofit Agency Serving People Who Are Severely Disabled

IC 28982 under ICR 201204-3037-003 · OMB 3037-0002.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 404 Annual Certification - Qualified Nonprofit Agency Serving People Who Are Severely Disabled	Form
404-Instructions 2012.docx	Instruction
404 Annual Certification - Qualified Nonprofit Agencies Serv 404 Form 2012.docx	Form

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	404	Annual Certification - Qualified Nonprofit Agencies Serving People Who Are Severely Disabled	404 Form 2012.docx		Yes	No	Paper Only
Instruction			404-Instructions 2012.docx		Yes	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 550

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	550	-5	555
Annual IC Time Burden (Hours)	3,300	-30	3,330
Annual IC Cost Burden (Dollars)	99,000	-900	99,900

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.