Information Collection

Application

IC 221499 under ICR 201605-0970-008 · OMB 0970-0482.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0482 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Application Form and Instruction
1 AV Application 2016 Attachment D_AV Application 2016 - Revised Draft.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	AV Application 2016	Attachment D_AV Application 2016 - Revised Draft.docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	54	54
Annual IC Time Burden (Hours)	540	540
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.