Income Analysis

The Health Center Program Application Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0285 can be found here:

Documents and Forms

Document Name Document Type
Form 3 Income Analysis Form
3 Income Analysis Form 3 - Income Analysis (track changes).doc Form
3 Income Analysis Final Form 3 - 2017.doc Form
3A Look alike Budget Form 3A - Look alike budget (track changes).doc Form and Instruction
3A Look Alike Budget Information Final Form 3A - 2017.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Income Analysis	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3	Income Analysis	Form 3 - Income Analysis (track changes).doc	Yes	Yes	Fillable Fileable
Form	3	Income Analysis Final	Form 3 - 2017.doc	Yes	Yes	Fillable Fileable
Form and Instruction	3A	Look alike Budget	Form 3A - Look alike budget (track changes).doc	Yes	Yes	Fillable Fileable
Form and Instruction	3A	Look Alike Budget Information Final	Form 3A - 2017.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	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	Previously Approved
Annual Number of Responses for this IC	2,000	400	1,600
Annual IC Time Burden (Hours)	4,850	50	4,800
Annual IC Cost Burden (Dollars)	0	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.