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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type

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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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.