Information Collection

WIC State Agency Evaluations

IC 209949 under ICR 201702-0584-001 · OMB 0584-0591.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0591 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment G Gold Application.docx [email protected]	Other-Attachment G Gold Application
Attachment H Gold Application Instructions.docx [email protected]	Instruction
Attachment I Gold Evaluation Instructions.docx [email protected]	Instruction
Attachment J Gold Evaluation Worksheet.docx [email protected]	Other-Attachment J Gold Evaluation W
Attachment K PremElite Application.docx [email protected]	Other-Attachment K PremElite Applica
Attachment L PremElite Application Instructions.docx [email protected]	Instruction
Attachment M PremElite Evaluation Instructions.docx [email protected]	Instruction
Attachment N PremElite Evaluation Worksheet.docx [email protected]	Other-Attachment N PremElite Evaluat
Attachment O LSA-FAQ-Page.pdf [email protected]	Other-Attachment O LSA-FAQ-Page

IC Title:

WIC State Agency Evaluations

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	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Attachment G Gold Application	Attachment G Gold Application.docx	[email protected]	Yes	Yes	Fillable Fileable Signable
Instruction	Attachment H Gold Application Instructions.docx	[email protected]	Yes	Yes	Printable Only
Instruction	Attachment I Gold Evaluation Instructions.docx	[email protected]	Yes	Yes	Printable Only
Other-Attachment J Gold Evaluation Worksheet	Attachment J Gold Evaluation Worksheet.docx	[email protected]	Yes	Yes	Fillable Fileable Signable
Other-Attachment K PremElite Application	Attachment K PremElite Application.docx	[email protected]	Yes	Yes	Fillable Fileable Signable
Instruction	Attachment L PremElite Application Instructions.docx	[email protected]	Yes	Yes	Printable Only
Instruction	Attachment M PremElite Evaluation Instructions.docx	[email protected]	Yes	Yes	Printable Only
Other-Attachment N PremElite Evaluation Worksheet	Attachment N PremElite Evaluation Worksheet.docx	[email protected]	Yes	Yes	Fillable Fileable Signable
Other-Attachment O LSA-FAQ-Page	Attachment O LSA-FAQ-Page.pdf	[email protected]	Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	363	-244	607
Annual IC Time Burden (Hours)	435	-293	728
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.