Information Collection

Payment File

IC 9939 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 1 Payment File Form
1 Input Record Specifications Input_Record_Specifications_(E_Charts) FINAL.docx Form
1 Output Record Specifications Output_Record_Specifications_(F_Charts) FINAL.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Payment File	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Input Record Specifications	Input_Record_Specifications_(E_Charts) FINAL.docx		Yes	Yes	Fillable Printable
Form	1	Output Record Specifications	Output_Record_Specifications_(F_Charts) FINAL.docx		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: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,808	2,808
Annual IC Time Burden (Hours)	379	379
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.