Individuals/Households

APPENDIX C30. NAMES SURVEY INCENTIVE RECEIVED FORM-SPANISH

Número OMB: 0584-XXXX

Fecha de vencimiento: XX/XX/XXXX

Recibo de incentivo

He recibido una tarjeta regalo por la cantidad de dólares que se indica a continuación por mi participación en el Encuesta Sobre la Evaluación Nacional de los Servicios e Idoneidad Alimentarios (NAMES por sus siglas en inglés).

$20—Por completar la encuesta

$50—Por completar la encuesta y suministro de documentación de ingresos

____________________________________

Nombre del participante (letra de imprenta)

____________________________________ _______________________

Firma del participante Fecha

(Respondent Copy)

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Recibo de incentivo

He recibido una tarjeta regalo por la cantidad de dólares que se indica a continuación por mi participación en el Encuesta Sobre la Evaluación Nacional de los Servicios e Idoneidad Alimentarios (NAMES por sus siglas en inglés).

$20—Por completar la encuesta

$50—Por completar la encuesta y suministro de documentación de ingresos

____________________________________

Nombre del participante (letra de imprenta)

____________________________________ _______________________

Firma del participante Fecha

(Westat Copy)

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information.

De acuerdo con la Ley de reducción de papeleo de 1995 (Paperwork Reduction Act of 1995), un organismo no debe llevar a cabo in auspiciar, y ninguna persona está obligada a responder a una recolección de información a menos que esta tenga un número válido de la OMB. El número de control válido de la OMB para esta recolección de información es 0584-XXX. Se calcula que el tiempo requerido para contestar esta recolección de información es de 2 minutos, incluyendo el tiempo para revisar las instrucciones, buscar fuentes existentes de datos, reunir y mantener los datos necesarios y completar y revisar la recolección de información.