Information Collection

HRSA 99-5 (Initial and Reconciliation)

IC 211220 under ICR 202210-0915-007 · OMB 0915-0247.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0247 can be found here:

Documents and Forms

Document Name Document Type
Form 99-5 I & R HRSA 99-5 (Initial and Reconciliation) Form
99-5 I & R HRSA 99-5 (Initial and Reconciliation) HRSA 99-5 (Initial and Reconciliation).docx Form
99-5 I & R HRSA 99-5 (Initial and Reconciliation) HRSA 99-5 (Initial and Reconciliation).docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	HRSA 99-5 (Initial and Reconciliation)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	99-5 I & R	HRSA 99-5 (Initial and Reconciliation)	HRSA 99-5 (Initial and Reconciliation).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	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: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	40	40
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.