Information Collection

Income Analysis

IC 180774 under ICR 201608-0915-003 · OMB 0915-0285.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.