Information Collection

Withdrawal of Application or Declination of Placement Form

IC 241922 under ICR 202206-0970-012 · OMB 0970-0550.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0550 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Withdrawal of Application or Declination of Placement Form Form
1 Withdrawal of Application or Declination of Placement Fo Withdrawal of Application or Declination of Placement Form_2.26.2020.docx Form
1 Withdrawal of Application or Declination of Placement Fo Withdrawal of Application or Declination of Placement Form_2.26.2020.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Withdrawal of Application or Declination of Placement Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Withdrawal of Application or Declination of Placement Form	Withdrawal of Application or Declination of Placement Form_2.26.2020.docx		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: 30	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	6	6
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.