Information Collection

Confirmation of Interest Form

IC 239776 under ICR 202212-0915-001 · OMB 0915-0140.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0140 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5-1 Confirmation of Interest Form	Form and Instruction
Form 5-1 Confirmation of Interest Form	Form and Instruction
5-1 NC LRP COI 1-Accept or Decline Award Page - Revised.docx NC LRP COI 1-Accept or Decline Award Page - Revised.docx	Form and Instruction
5-1 NC LRP COI 1-Accept or Decline Award Page - Revised.docx NC LRP COI 1-Accept or Decline Award Page - Revised.docx	Form and Instruction
5-2 NC LRP COI 2-Electronic Withholding Allowance Certificat NC LRP COI 2-Electronic Withholding Allowance Certificate Page - Revised.docx	Form and Instruction
5-2 NC LRP COI 2-Electronic Withholding Allowance Certificat NC LRP COI 2-Electronic Withholding Allowance Certificate Page - Revised.docx	Form and Instruction
5-3 NC LRP COI 3-Sign your Electronic Contract Page - Revise NC LRP COI 3-Sign your Electronic Contract Page - Revised.docx	Form and Instruction
5-3 NC LRP COI 3-Sign your Electronic Contract Page - Revise NC LRP COI 3-Sign your Electronic Contract Page - Revised.docx	Form and Instruction
5-4 NC LRP COI 4-Submitted Landing Page - Revised.docx NC LRP COI 4-Submitted Landing Page - Revised.docx	Form and Instruction
5-4 NC LRP COI 4-Submitted Landing Page - Revised.docx NC LRP COI 4-Submitted Landing Page - Revised.docx	Form and Instruction

IC Title:

Confirmation of Interest Form

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5-1	NC LRP COI 1-Accept or Decline Award Page - Revised.docx	NC LRP COI 1-Accept or Decline Award Page - Revised.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5-2	NC LRP COI 2-Electronic Withholding Allowance Certificate Page - Revised.docx	NC LRP COI 2-Electronic Withholding Allowance Certificate Page - Revised.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5-3	NC LRP COI 3-Sign your Electronic Contract Page - Revised.docx	NC LRP COI 3-Sign your Electronic Contract Page - Revised.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5-4	NC LRP COI 4-Submitted Landing Page - Revised.docx	NC LRP COI 4-Submitted Landing Page - Revised.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	100	100
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.