Information Collection

Part B Allocation and Expenditure forms

IC 183273 under ICR 201909-0915-004 · OMB 0915-0318.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0318 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Part B Allocation and Expenditure forms	Form
Part B Allocations Report - instructions.docx	Instruction
CLC - instructions.pdf	Instruction
B3 CLC CLC.pdf	Form
1 Part B Allocations Suppl Allocations Report_combined 13M Part B Allocations Suppl Allocations Report_combined 13Mar2017_modified 7242017.xlsx	Form
2 Part B Expenditures Report Suppl Expenditures_combined u Part B Expenditures Report Suppl Expenditures_combined updated4132017_modified 7242017.xlsx	Form

IC Title:

Part B Allocation and Expenditure forms

Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Part B Allocations Suppl Allocations Report_combined 13Mar2017_	Part B Allocations Suppl Allocations Report_combined 13Mar2017_modified 7242017.xlsx	Yes	Yes	Fillable Fileable
Form	2	Part B Expenditures Report Suppl Expenditures_combined updated	Part B Expenditures Report Suppl Expenditures_combined updated4132017_modified 7242017.xlsx	Yes	Yes	Fillable Fileable
Instruction			Part B Allocations Report - instructions.docx	Yes	Yes	Fillable Fileable
Form	B3	CLC	CLC.pdf	Yes	Yes	Fillable Fileable
Instruction			CLC - instructions.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

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	Previously Approved
Annual Number of Responses for this IC	162	162
Annual IC Time Burden (Hours)	324	324
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.