Information Collection

UAC Questionnaires (Forms M-12A-B, E) - Recordkeeping

IC 245615 under ICR 202107-0970-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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, E) - Recordkeeping	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-12E UC Questionnaire - Ages 5 and Under UC Questionnaire - Ages 5 and Under (Form M-12E).docx	Form and Instruction

IC Title:

UAC Questionnaires (Forms M-12A-B, E) - Recordkeeping

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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
Form and Instruction	Form M-12E	UC Questionnaire - Ages 5 and Under	UC Questionnaire - Ages 5 and Under (Form M-12E).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: 4

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	132	132
Annual IC Time Burden (Hours)	66	66
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.