Information Collection

UAC Questionnaires (Forms M-12A-B) - Respondents

IC 245614 under ICR 202102-0970-001 · OMB 0970-0564.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0564 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form M-12A UAC Questionnaires (Forms M-12A-B) - Respondents	Form and Instruction
Form M-12A UAC Questionnaire - Ages 6-12 Years Old 44 - UAC Questionnaire - Ages 6-12 Years Old (Form M-12A).docx	Form and Instruction
Form M-12A UAC Questionnaire - Ages 6-12 Years Old 44 - UAC Questionnaire - Ages 6-12 Years Old (Form M-12A).docx	Form and Instruction
Form M-12B UAC Questionnaire - Ages 13 and Older 45 - UAC Questionnaire - Ages 13 and Older (Form M-12B).docx	Form and Instruction
Form M-12B UAC Questionnaire - Ages 13 and Older 45 - UAC Questionnaire - Ages 13 and Older (Form M-12B).docx	Form and Instruction

IC Title:

UAC Questionnaires (Forms M-12A-B) - Respondents

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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 and Instruction	Form M-12A	UAC Questionnaire - Ages 6-12 Years Old	44 - UAC Questionnaire - Ages 6-12 Years Old (Form M-12A).docx		Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12B	UAC Questionnaire - Ages 13 and Older	45 - UAC Questionnaire - Ages 13 and Older (Form M-12B).docx		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: 460

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	460	460
Annual IC Time Burden (Hours)	230	230
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.