Information Collection

Certification of Maintenance of Effort

IC 10263 under ICR 201710-0985-004 · OMB 0985-0009.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0985-0009 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Certification of Maintenance of Effort	Form
1 Certification of Maintenance Certification of Maintenance Form.docx	Form
2 Certification of Long Term Care Ombudsman Program Expend Certification of LTCO Program Expenditures.docx	Form

IC Title:

Certification of Maintenance of Effort

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 1321.49

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	1	Certification of Maintenance	Certification of Maintenance Form.docx		Yes	Yes	Fillable Fileable
Form	2	Certification of Long Term Care Ombudsman Program Expenditures	Certification of LTCO Program Expenditures.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	28	28
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.