WIC State Agency Evaluations

The Loving Support Award of Excellence

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.