Information Collection

Block Grant Application

IC 7545 under ICR 202104-0930-002 · OMB 0930-0168.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0168 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form BG Application Block Grant Application	Form and Instruction
BG Application BG Application 04.17.2019 FFY 2020-2021 Block Grant Application and Plan CLEAN.docx	Form and Instruction
BG Application BG Application 04.17.2019 FFY 2020-2021 Block Grant Application and Plan CLEAN.docx	Form and Instruction
FFY 2020-2021 MHBG Report.pdf MH BG Report	IC Document
FFY 2020-2021 MHBG Report.pdf MH BG Report	IC Document
FY 2020-2021SABG Report.pdf SA BG Report	IC Document
FY 2020-2021SABG Report.pdf SA BG Report	IC Document
FY20-21 MHBG-funding-agreements.pdf MH BG Funding Agreements	IC Document
FY20-21 MHBG-funding-agreements.pdf MH BG Funding Agreements	IC Document
FY20-21 SABG-funding-agreements.pdf SA BG Funding Agreements	IC Document
FY20-21 SABG-funding-agreements.pdf SA BG Funding Agreements	IC Document

IC Title:

Block Grant Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

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	BG Application	BG Application	04.17.2019 FFY 2020-2021 Block Grant Application and Plan CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 119

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	119	119
Annual IC Time Burden (Hours)	33,374	33,374
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MH BG Report	FFY 2020-2021 MHBG Report.pdf	01/08/2019
SA BG Report	FY 2020-2021SABG Report.pdf	01/08/2019
MH BG Funding Agreements	FY20-21 MHBG-funding-agreements.pdf	01/08/2019
SA BG Funding Agreements	FY20-21 SABG-funding-agreements.pdf	01/08/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.