Information Collection

Financcial Mapping Interview

IC 214518 under ICR 201501-0930-003 · OMB 0930-0349.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Financial Mapping Financcial Mapping Interview	Form and Instruction
Financial Mapping Financial Mapping Interview Attachment 6 Financial Mapping Interview 12-17-14.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

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 and Instruction	Financial Mapping Interview	Financial Mapping Interview	Attachment 6 Financial Mapping Interview 12-17-14.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 129

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	129	129
Annual IC Time Burden (Hours)	269	269
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.