Appendix A-10a Pretest Incentive Receipt English_2_26_19

OMB Control No: 0584-0606

Expiration Date: 03/31/2019

Appendix A-10a: Pretest Incentive Receipts, English

Incentive receipts

I have received $40 from [Westat/Social Policy Research] to offset any costs such as childcare or traveling that I may have incurred by my participation in pretesting the SNAP and Work survey.

Printed Name: ________________________________

Signature: ____________________________________

Date: _______________________________________

Public reporting burden for this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0606). Do not return the completed form to this address.