Information Collection

Authorization for Release of Records (Form A-5 & A-5s)

IC 241072 under ICR 202109-0970-014 · OMB 0970-0547.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0547 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form A-5 Authorization for Release of Records (Form A-5)	Form
A-5 Authorization for Release of Records Authorization for Release of Records (Form A-5) - PDF.pdf	Form
A-5 Authorization for Release of Records A-5 Authorization for Release of Records 04.08.22.pdf	Form
A-5s Authorization for Release of Records - Spanish A-5s Authorization for Release of Records - final 05.03.22.pdf	Form

IC Title:

Authorization for Release of Records (Form A-5 & A-5s)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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	A-5	Authorization for Release of Records	A-5 Authorization for Release of Records 04.08.22.pdf		Yes	Yes	Fillable Fileable
Form	A-5s	Authorization for Release of Records - Spanish	A-5s Authorization for Release of Records - final 05.03.22.pdf		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: 4,000

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,000	0	4,000
Annual IC Time Burden (Hours)	1,000	333	667
Annual IC Cost Burden (Dollars)	0	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.