Information Collection

Application and start up

IC 201794 under ICR 201211-1205-002 · OMB 1205-0492.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Application Checklist.doc	Other-checklist
Draft demonstration agreement.rtf Agreement	IC Document

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
Other-checklist			Application Checklist.doc		Yes	Yes	Paper Only

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10	0	10
Annual IC Time Burden (Hours)	2,400	0	2,400
Annual IC Cost Burden (Dollars)	0	-98,340	98,340

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Agreement	Draft demonstration agreement.rtf	04/02/2012

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