Information Collection

Certification of Domestic Violence, Dating Violence, or Stalking

IC 46037 under ICR 201312-2577-003 · OMB 2577-0249.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form HUD-50066 Certification of Domestic Violence, Dating Violence, or Stalking	Form
HUD-50066 Certification of Domestic Violence, Dating Violence, or HUD 50066 - Original Version.doc	Form
HUD-50066 (Revised Certification of Domestic Violence, Dating Violence, or HUD 50066_Revised Version.doc	Form and Instruction

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: 24 CFR 5

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
Form	HUD-50066	Certification of Domestic Violence, Dating Violence, or Stalking	HUD 50066 - Original Version.doc		Yes	Yes	Fillable Fileable
Form and Instruction	HUD-50066 (Revised Version)	Certification of Domestic Violence, Dating Violence, or Stalking	HUD 50066_Revised Version.doc		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

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	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	4,800	4,800

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.