Information Collection

State Agencies

IC 218873 under ICR 202203-0584-005 · OMB 0584-0605.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Appendix C Email from Regional FNS Offices.pdf Appendix C Email from Regional FNS Offices	IC Document
Appendix C Email from Regional FNS Offices.pdf Appendix C Email from Regional FNS Offices	IC Document
Appendix C.1 Email from National FNS Office.pdf Appendix C.1 Email from National FNS Office	IC Document
Appendix C.1 Email from National FNS Office.pdf Appendix C.1 Email from National FNS Office	IC Document
Appendix D 4032 Policy Memo.pdf Appendix D 4032 Policy Memo	IC Document
Appendix D 4032 Policy Memo.pdf Appendix D 4032 Policy Memo	IC Document

IC Title:

State Agencies

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 7 CFR 272.14 and 273.16

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: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title: USDA/FNSâ5, Information on Persons Disqualified from the Supplemental Nutrition Assistance

FR Citation: 75 FR 81205

Number of Respondents: 106

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	212	212
Annual IC Time Burden (Hours)	119	119
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix C Email from Regional FNS Offices		04/12/2022
Appendix C.1 Email from National FNS Office		04/12/2022
Appendix D 4032 Policy Memo		04/12/2022

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

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