Income Verification

Health Eligibility Center (HEC) Income Verification (IV) Forms

Documents and Forms

Document Name Document Type
Form 200-1A Income Verification Form
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
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

Information Collection (IC) Details

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	200-1A	Income Verification Response	FUTURE Word Version - 200-1A - VETERAN - INCOME VERIFICATION RESPONSE-OMB Encl1.doc	No	Paper Only
Form	220-1	Spouse - Income Verification Response	Word Doc Future 220-1 SPOUSE 06 24 2016-OMB Encl 2.doc	No	Paper Only
Form	340-1	Declaration of Representative	Word Doc Future 340-1 Encl 3-.doc	No	Paper Only
Other-Checklist			Word Doc Future Checklist Encl 4-.doc	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 %

	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

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.