Information Collection

Income Verification

IC 221774 under ICR 202010-2900-006 · OMB 2900-0867.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0867 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 200-1A Income Verification	Form
Form 200-1A Income Verification Response Income Verification	Form
Form 220-1 Spouse - Income Verification Response Income Verification	Form
Form 340-1 Declaration of Representative Income Verification	Form
Word Doc Future Checklist Encl 4-.doc	Other-Checklist
Word Doc Future Checklist Encl 4-.doc	Other-Checklist
200-1A Income Verification Response FUTURE Word Version - 200-1A - VETERAN - INCOME VERIFICATION RESPONSE-OMB Encl1.doc	Form
200-1A Income Verification Response FUTURE Word Version - 200-1A - VETERAN - INCOME VERIFICATION RESPONSE-OMB Encl1.doc	Form
220-1 Spouse - Income Verification Response Word Doc Future 220-1 SPOUSE 06 24 2016-OMB Encl 2.doc	Form
220-1 Spouse - Income Verification Response Word Doc Future 220-1 SPOUSE 06 24 2016-OMB Encl 2.doc	Form
340-1 Declaration of Representative Word Doc Future 340-1 Encl 3-.doc	Form
340-1 Declaration of Representative Word Doc Future 340-1 Encl 3-.doc	Form

IC Title:

Income Verification

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Form	200-1A	No	Paper Only
Form	220-1	No	Paper Only
Form	340-1	No	Paper Only
Other-Checklist		No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 273,441

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-273,441	273,441
Annual IC Time Burden (Hours)	-119,993	119,993
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].