Information Collection

Notice of Rights and Provision of Services Handout

IC 222322 under ICR 201606-0970-005 · OMB 0970-0498.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Notice of Rights and Provision of Services Handout	Form and Instruction
1 Notice of Rights and Provision of Services Handout Notice of Rights and Provision of Services Handout.pdf	Form and Instruction

IC Title:

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	Notice of Rights and Provision of Services Handout	Notice of Rights and Provision of Services Handout.pdf		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: 100

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	34,000	34,000
Annual IC Time Burden (Hours)	3,400	3,400
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.