Confirmation of Interest Form

NURSE Corps Loan Repayment Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0140 can be found here:

Documents and Forms

Document Name Document Type
Form 5-1 Confirmation of Interest Form Form and Instruction
5-1 NC LRP COI 1-Accept or Decline Award Page - Revised.docx NC LRP COI 1-Accept or Decline Award Page - Revised.docx Form and Instruction
5-2 NC LRP COI 2-Electronic Withholding Allowance Certificat NC LRP COI 2-Electronic Withholding Allowance Certificate Page - Revised.docx Form and Instruction
5-3 NC LRP COI 3-Sign your Electronic Contract Page - Revise NC LRP COI 3-Sign your Electronic Contract Page - Revised.docx Form and Instruction
5-4 NC LRP COI 4-Submitted Landing Page - Revised.docx NC LRP COI 4-Submitted Landing Page - Revised.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Confirmation of Interest 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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5-1	NC LRP COI 1-Accept or Decline Award Page - Revised.docx	NC LRP COI 1-Accept or Decline Award Page - Revised.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5-2	NC LRP COI 2-Electronic Withholding Allowance Certificate Page - Revised.docx	NC LRP COI 2-Electronic Withholding Allowance Certificate Page - Revised.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5-3	NC LRP COI 3-Sign your Electronic Contract Page - Revised.docx	NC LRP COI 3-Sign your Electronic Contract Page - Revised.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5-4	NC LRP COI 4-Submitted Landing Page - Revised.docx	NC LRP COI 4-Submitted Landing Page - Revised.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.