Information Collection

Employer Services Agreement and Profile

IC 233423 under ICR 202205-0970-005 · OMB 0970-0370.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0370 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Employer Services Agreement and Profile	Form and Instruction
1 Employer Services Agreement and Profile 1 - 0970-0370_Employer Services Profile_020422.pdf	Form and Instruction
1 Employer Services Agreement and Profile 1 - 0970-0370_Employer Services Profile_020422.pdf	Form and Instruction

IC Title:

Employer Services Agreement and Profile

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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 and Instruction	1	Employer Services Agreement and Profile	1 - 0970-0370_Employer Services Profile_020422.pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,508

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	9,508	9,508
Annual IC Time Burden (Hours)	761	761
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.