Information Collection

Annex D: Application for Modification of a Decision, including Restricted Information on the Applicant

IC 224048 under ICR 202212-0970-004 · OMB 0970-0488.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0488 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Annex D: Application for Modification of a Decision, including Restricted Information on the Applicant	Form and Instruction
1 Application for Modification of a Decision Annex D_Application_for_Modification_of_a_Decision OMB.docx	Form and Instruction
1 Application for Modification of a Decision Annex D_Application_for_Modification_of_a_Decision OMB.docx	Form and Instruction

IC Title:

Annex D: Application for Modification of a Decision, including Restricted Information on the Applicant

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	Application for Modification of a Decision	Annex D_Application_for_Modification_of_a_Decision OMB.docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 54

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 50 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	216	216
Annual IC Time Burden (Hours)	108	108
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.