Information Collection

1305.4(l) Eligibility determination records (sample form)

IC 219441 under ICR 201512-0970-004 · OMB 0970-0374.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0374 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 1305.4(l) Eligibility determination records (sample form)	Form and Instruction
1 Sample eligibility form HS eligibiliy verification form 7-13-15 (3).docx	Form and Instruction

IC Title:

1305.4(l) Eligibility determination records (sample form)

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	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Sample eligibility form	HS eligibiliy verification form 7-13-15 (3).docx		No		Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,600

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	764,800	764,800
Annual IC Time Burden (Hours)	76,480	76,480
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.