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OMB Number: 0584-0613 |
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Expiration Date: 02/28/2021 |
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| Contact Information at Local [INSERT PROGRAM NAME] |
| Local [INSERT PROGRAM NAME] Agency |
Director First Name |
Director Last Name |
Position Title |
Telephone Number |
Email Address |
Mailing Address |
City |
State |
ZIP |
| [LOCAL AGENCY 1] |
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| [LOCAL AGENCY 2] |
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| [LOCAL AGENCY 3] |
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| According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The vaild OMB control |
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| number for this information collection is 0584-0613. The time required for the State Special Nutrition Program Director to complete this information collection is estimated to average 60 minutes per response, including the time |
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| for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. |
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