Information Collection

WIC State Agency Evaluations

IC 209949 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⚠️ Notice: This information collection may be referencing outdated material.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_O_GoldEvaluationInstructions2-4-14.pdf https://[email protected]	Instruction
Attachment_P_GoldEvalWrksht2-4-14.pdf https://[email protected]	Other-Gold Evaluation Worksheet
Attachment_S_GoldPremGoldEliteEvaluatorInstructions2-5-14.pdf https://[email protected]	Instruction
Attachment_T_GoldPremGoldEliteEvalWrksht2-5-14.pdf https://[email protected]	Other-GoldPremGoldElite Worksheet

IC Title:

WIC State Agency Evaluations

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
Instruction	Attachment_S_GoldPremGoldEliteEvaluatorInstructions2-5-14.pdf	https://[email protected]	Yes	Yes	Fillable Fileable Signable
Instruction	Attachment_O_GoldEvaluationInstructions2-4-14.pdf	https://[email protected]	Yes	Yes	Fillable Fileable Signable
Other-Gold Evaluation Worksheet	Attachment_P_GoldEvalWrksht2-4-14.pdf	https://[email protected]	Yes	Yes	Fillable Fileable Signable
Other-GoldPremGoldElite Worksheet	Attachment_T_GoldPremGoldEliteEvalWrksht2-5-14.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: 90

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	607	607
Annual IC Time Burden (Hours)	728	728
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.