Information Collection

Part B Allocation and Expenditure forms

IC 183273 under ICR 201703-0915-002 · OMB 0915-0318.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0318 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form B1 Part B Allocation and Expenditure forms	Form
Part B Allocations Report - instructions.docx	Instruction
CLC - instructions.pdf	Instruction
B1 Part B Allocations Suppl Allocations Report.xlsx Part B Allocations Suppl Allocations Report_combined 9MAR2017.xlsx	Form
B2 Part B Expenditures Suppl Allocations Report.xlsx Part B Expenditures Suppl Allocations Report_combined 9MAR2017.xlsx	Form
B3 CLC CLC.pdf	Form

IC Title:

Part B Allocation and Expenditure forms

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	B1	Part B Allocations Suppl Allocations Report.xlsx	Part B Allocations Suppl Allocations Report_combined 9MAR2017.xlsx	Yes	Yes	Fillable Fileable
Form	B2	Part B Expenditures Suppl Allocations Report.xlsx	Part B Expenditures Suppl Allocations Report_combined 9MAR2017.xlsx	Yes	Yes	Fillable Fileable
Instruction			Part B Allocations Report - instructions.docx	Yes	Yes	Fillable Fileable
Form	B3	CLC	CLC.pdf	Yes	Yes	Fillable Fileable
Instruction			CLC - instructions.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	162	52	110
Annual IC Time Burden (Hours)	324	-996	1,320
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.