Information Collection

Election Form

IC 10015 under ICR 201706-0970-006 · OMB 0970-0196.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0196 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Election Form	Form and Instruction
1 MSFIDM Election Form and Instructions 2016_12_30_MSFIDM_Election_Form_and_Instructions.docx	Form and Instruction

IC Title:

Election Form

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	MSFIDM Election Form and Instructions	2016_12_30_MSFIDM_Election_Form_and_Instructions.docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

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	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	673	673

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.