Information Collection

Coverage Assistance Fund (CAF) Application

IC 251211 under ICR 202201-0906-002 · OMB 0906-0069.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Coverage Assistance Fund (CAF) Application	Form
3 CAF Application Screenshots.pdf CAF Application Screenshots.pdf	Form
3 CAF Application Screenshots.pdf CAF Application Screenshots.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	3	CAF Application Screenshots.pdf	CAF Application Screenshots.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,000

Number of Respondents for Small Entity: 1,000

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15,000	15,000
Annual IC Time Burden (Hours)	15,000	15,000
Annual IC Cost Burden (Dollars)	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.