Information Collection

Application

IC 7545 under ICR 201503-0930-005 · OMB 0930-0168.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0168 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form BG Application Application	Form and Instruction
BG Application BG Application BG Application FY16-17.pdf	Form and Instruction
FY16-17 SABG Reporting.pdf SABG Reporting	IC Document
FY16 17 MHBG Reporting.pdf MHBG Reporting	IC Document
FY 16-17 SABG-funding-agreements.pdf SABG Funding-agreements	IC Document
FY 16-17 MHBG-funding-agreements.pdf MHBG Funding-agreements	IC Document

IC Title:

Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	BG Application	BG Application	BG Application FY16-17.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 119

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	Previously Approved
Annual Number of Responses for this IC	119	119
Annual IC Time Burden (Hours)	37,429	37,429
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SABG Reporting	FY16-17 SABG Reporting.pdf	06/12/2015
MHBG Reporting	FY16 17 MHBG Reporting.pdf	06/12/2015
SABG Funding-agreements	FY 16-17 SABG-funding-agreements.pdf	06/12/2015
MHBG Funding-agreements	FY 16-17 MHBG-funding-agreements.pdf	06/12/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.