Information Collection

WIC Local Agency Applications

IC 209947 under ICR 201312-0584-001 · OMB 0584-0591.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0591 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment_M_GoldApplication 2-4-14.pdf https://[email protected]	Other-Gold Application
Attachment_N_GoldApplicationInstructions2-4-14.pdf https://[email protected]	Instruction
Attachment_Q_GoldPremGoldEliteApplication02-05-14.pdf https://[email protected]	Other-PremElite Applciation
Attachment_R_GoldPremGoldEliteApplicationsInstructions2-4-14.pdf https://[email protected]	Instruction

IC Title:

WIC Local Agency Applications

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	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Gold Application	Attachment_M_GoldApplication 2-4-14.pdf	https://[email protected]	Yes	Yes	Fillable Fileable Signable
Instruction	Attachment_N_GoldApplicationInstructions2-4-14.pdf	https://[email protected]	Yes	Yes	Fillable Fileable Signable
Other-PremElite Applciation	Attachment_Q_GoldPremGoldEliteApplication02-05-14.pdf	https://[email protected]	Yes	Yes	Fillable Fileable Signable
Instruction	Attachment_R_GoldPremGoldEliteApplicationsInstructions2-4-14.pdf	https://[email protected]	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 607

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	607	607
Annual IC Time Burden (Hours)	1,214	1,214
Annual IC Cost Burden (Dollars)	0	0

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.