Information Collection

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

IC 245615 under ICR 202112-0970-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 UC Questionnaires (Forms M-12A-B, E) - Recordkeeping	Form and Instruction
Form M-12A UC Questionnaire - Ages 6-12 Years Old - English M-12A UC Questionnaire - Ages 6-12 Years Old - Clean.docx	Form and Instruction
Form M-12A UC Questionnaire - Ages 6-12 Years Old - English M-12A UC Questionnaire - Ages 6-12 Years Old - Clean.docx	Form and Instruction
Form M-12B UC Questionnaire - Ages 13 and Older - English M-12B UC Questionnaire - Ages 13 and Older - Clean.docx	Form and Instruction
Form M-12B UC Questionnaire - Ages 13 and Older - English M-12B UC Questionnaire - Ages 13 and Older - Clean.docx	Form and Instruction
Form M-12E UC Questionnaire - Ages 5 and Under - English UC Questionnaire - Ages 5 and Under - English (Form M-12E).docx	Form and Instruction
Form M-12E UC Questionnaire - Ages 5 and Under - English UC Questionnaire - Ages 5 and Under - English (Form M-12E).docx	Form and Instruction
Form M-12As UC Questionnaire - Ages 6-12 Years Old - Spanish UC Questionnaire - Ages 6-12 Years Old - Spanish (Form M-12As).docx	Form and Instruction
Form M-12As UC Questionnaire - Ages 6-12 Years Old - Spanish UC Questionnaire - Ages 6-12 Years Old - Spanish (Form M-12As).docx	Form and Instruction
Form M-12Bs UC Questionnaire - Ages 13 and Older - Spanish UC Questionnaire - Ages 13 and Older - Spanish (Form M-12Bs).docx	Form and Instruction
Form M-12Bs UC Questionnaire - Ages 13 and Older - Spanish UC Questionnaire - Ages 13 and Older - Spanish (Form M-12Bs).docx	Form and Instruction
Form M-12Es UC Questionnaire - Ages 5 and Under - Spanish UC Questionnaire - Ages 5 and Under - Spanish (Form M-12Es).docx	Form and Instruction
Form M-12Es UC Questionnaire - Ages 5 and Under - Spanish UC Questionnaire - Ages 5 and Under - Spanish (Form M-12Es).docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

UC 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	UC Questionnaire - Ages 6-12 Years Old - English	M-12A UC Questionnaire - Ages 6-12 Years Old - Clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12B	UC Questionnaire - Ages 13 and Older - English	M-12B UC Questionnaire - Ages 13 and Older - Clean.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12E	UC Questionnaire - Ages 5 and Under - English	UC Questionnaire - Ages 5 and Under - English (Form M-12E).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12As	UC Questionnaire - Ages 6-12 Years Old - Spanish	UC Questionnaire - Ages 6-12 Years Old - Spanish (Form M-12As).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12Bs	UC Questionnaire - Ages 13 and Older - Spanish	UC Questionnaire - Ages 13 and Older - Spanish (Form M-12Bs).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-12Es	UC Questionnaire - Ages 5 and Under - Spanish	UC Questionnaire - Ages 5 and Under - Spanish (Form M-12Es).docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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