Information Collection

Financial Capability Form

IC 222054 under ICR 202211-1122-002 · OMB 1122-0030.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1122-0030 can be found here:

Documents and Forms

Document Name Document Type
Form 1122-0030 Financial Capability Form Form
1122-0030 APPLICANT FINANCIAL CAPABILITY QUESTIONNAIRE omb_approved_afcq_sept_2016.pdf www.justice.gov/ovw/file/866126/download Form
1122-0030 APPLICANT FINANCIAL CAPABILITY QUESTIONNAIRE omb_approved_afcq_sept_2016.pdf www.justice.gov/ovw/file/866126/download Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Financial Capability Form	Agency IC Tracking Number:	1122-0030

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	1122-0030	APPLICANT FINANCIAL CAPABILITY QUESTIONNAIRE	omb_approved_afcq_sept_2016.pdf	https://www.justice.gov/ovw/file/866126/download	Yes	Yes	Fillable Fileable Signable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 40

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	40	40
Annual IC Time Burden (Hours)	160	160
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.