Information Collection

Adoptive Family Relief Act Refund Application

IC 221041 under ICR 201912-1405-004 · OMB 1405-0223.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0223 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-7781 Adoptive Family Relief Act Refund Application	Form
DS-7781 Adoptive Family Relief Act Refund Application DS-7781.pdf	Form

IC Title:

Adoptive Family Relief Act Refund Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	DS-7781	Adoptive Family Relief Act Refund Application	DS-7781.pdf		Yes	No	Fillable Printable

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	20	-580	600
Annual IC Time Burden (Hours)	2	-48	50
Annual IC Cost Burden (Dollars)	94	94	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.