Information Collection

State, Local and Tribal Agencies (Non-Respondents)

IC 228064 under ICR 201708-0584-002 · OMB 0584-0633.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Non-Respondent Placeholder.docx www.qualtrics.com	Other-NON RESPONDENT INSTRUMENT

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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
Other-NON RESPONDENT INSTRUMENT			Non-Respondent Placeholder.docx	www.qualtrics.com	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 151

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
Annual Number of Responses for this IC	151	151
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	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.