Information Collection

Financial Capability Form

IC 222054 under ICR 201905-1122-001 · OMB 1122-0030.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1122-0030 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1122-XXXX Financial Capability Form	Form
1122-XXXX Financial Capability Form Revised FCQ for OVW 2016.docx www.usdoj.gov/ovw	Form

IC Title:

Financial Capability Form

Agency IC Tracking Number:

1122-XXXX

Is this a Common Form? No

IC Status: Unchanged

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	1122-XXXX	Financial Capability Form	Revised FCQ for OVW 2016.docx	www.usdoj.gov/ovw	Yes	Yes	Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 40

Number of Respondents for Small Entity: 40

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	160	160
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.