Information Collection

Annex D: Status of Application Report-Article 12

IC 224049 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⚠️ Notice: This information collection may be referencing outdated material.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: Status of Application Report-Article 12	Form and Instruction
1 Status of Application Report Article 12 Annex_D Status_of_Application_Report_Article12 OMB.docx	Form and Instruction
1 Status of Application Report Article 12 Annex_D Status_of_Application_Report_Article12 OMB.docx	Form and Instruction

IC Title:

Annex D: Status of Application Report-Article 12

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:

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	Status of Application Report Article 12	Annex_D Status_of_Application_Report_Article12 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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	432	-54	486
Annual IC Time Burden (Hours)	143	-17	160
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.