WIC State Agency Evaluations

The Loving Support Award of Excellence

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.