Information Collection

SELRP - Mobility Agreement

IC 241716 under ICR 202102-2900-002 · OMB 2900-0879.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10-255d SELRP - Mobility Agreement	Form and Instruction
10-255d Specialty Education Loan Repayment Program (SELRP) - Mob VA Form 10-255d_SELRP Mobility Agreement.pdf	Form and Instruction
10-255d Specialty Education Loan Repayment Program (SELRP) - Mob VA Form 10-255d_SELRP Mobility Agreement.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

2900-NEW

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 38 CFR 17

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	10-255d	Specialty Education Loan Repayment Program (SELRP) - Mobility Agreement	VA Form 10-255d_SELRP Mobility Agreement.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 200

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	200	200
Annual IC Time Burden (Hours)	33	33
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.