Information Collection

Withdrawl of Application or Declination of Placement Form

IC 222325 under ICR 201606-0970-005 · OMB 0970-0498.

Documents and Forms

Document Name Document Type
Form 1 Withdrawl of Application or Declination of Placement Form Form and Instruction
1 URM Withdrawal or Declination of Particiapation URM Withdrawal or Declination of Participation.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Withdrawl of Application or Declination of Placement Form	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	URM Withdrawal or Declination of Particiapation	URM Withdrawal or Declination of Participation.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: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	10	10
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.