Information Collection

Release Request (Form R-4) – Grantee Case Managers

IC 242802 under ICR 202109-0970-019 · OMB 0970-0552.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0552 can be found here:

Documents and Forms

Document Name Document Type
Form R-4 Release Request (Form R-4) – Grantee Case Managers Form and Instruction
R-4 Release Request - UC Path Version Release Request (Form R-4) - UC Path.pdf Form and Instruction
R-4 Release Request - UC Path Version Release Request (Form R-4) - Revised.pdf Form and Instruction
R-4 Release Request - UC Portal Version Release Request (Form R-4) - UC Portal.pdf Form and Instruction
R-4 Release Request - UC Portal Version Release Request (Form R-4) - Current.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Release Request (Form R-4) â Grantee Case Managers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	R-4	Release Request - UC Path Version	Release Request (Form R-4) - Revised.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	R-4	Release Request - UC Portal Version	Release Request (Form R-4) - Current.pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title: 09-80-0321 ORR Division of Children's Services Records	FR Citation: 81 FR 46682

Number of Respondents: 216	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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	54,864	-18,472	73,336
Annual IC Time Burden (Hours)	22,860	-32,142	55,002
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.