Information Collection

COVID-19 Supplemental Payment Requests

IC 242755 under ICR 202110-2502-004 · OMB 2502-0619.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2502-0619 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	COVID-19 Supplemental Payment Requests	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 2

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 23,200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	23,200	23,200
Annual IC Time Burden (Hours)	25,520	25,520
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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