Information Collection

Annual Certification Letter

IC 179583 under ICR 201603-0970-001 · OMB 0970-0161.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0161 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Annual Certification Letter	Form and Instruction
1 Annual Certification Letter Annual_Certification_Letter_FINAL.v2.doc	Form and Instruction

IC Title:

Annual Certification Letter

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	1	Annual Certification Letter	Annual_Certification_Letter_FINAL.v2.doc		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Location and Collection System

FR Citation: 78 FR 5812

Number of Respondents: 54

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	54	54
Annual IC Time Burden (Hours)	22	22
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.