FDPIR Participants (Individuals/Househoulds)

OMB NUMBER: 0584-XXXX

EXPIRATION DATE: XX-XX-20XX

ATTACHMENT B5c: DISCUSSION GROUP PARTICIPANT GIFT CONFIRMATION

BURDEN DISCLOSURE STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 1 minute per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

The Urban Institute

Discussion Group Participant Gift Confirmation

Site: _____________________________________

Date: ________________________ Time: ________________________

By signing below, I confirm that I received $25 as a token of appreciation at the conclusion of the discussion group conducted by the [Urban Institute/Support Services International] regarding food assistance programs, including the Food Distribution Program on Indian Reservations.

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 1 minute per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.