Information Collection

Client Service Use and Delivery Form

IC 237960 under ICR 201910-0970-001 · OMB 0970-0467.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0467 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Client Service Use and Delivery Form	Form
2 Client Service Use and Delivery Form Attachment D - OTIP-0499 - TVAP Revision - Client Service Use and Delivery Form_10.01.19.pdf	Form

IC Title:

Client Service Use and Delivery Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	2	Client Service Use and Delivery Form	Attachment D - OTIP-0499 - TVAP Revision - Client Service Use and Delivery Form_10.01.19.pdf		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: 1,100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,100	1,100
Annual IC Time Burden (Hours)	275	275
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.