Information Collection

Eligibility Questionnaire For Havana Act Payments

IC 259317 under ICR 202302-0690-001 · OMB 0690-0037.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0690-0037 can be found here:

Documents and Forms

Document Name Document Type
Form CD-350 ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS Form and Instruction
Form CD-350 ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS Form and Instruction
RELATIONSHIP DOCS - HAVANA Act Payments Collection.docx Instruction
CD-350 ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS FINAL CD-350 Eligibility Questionnaire for HAVANA Act Payments.pdf Form and Instruction
CD-350 ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS FINAL CD-350 Eligibility Questionnaire for HAVANA Act Payments.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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 and Instruction	CD-350	ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS	FINAL CD-350 Eligibility Questionnaire for HAVANA Act Payments.pdf		No		Fillable Printable
Instruction			RELATIONSHIP DOCS - HAVANA Act Payments Collection.docx		Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	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: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	20	20
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.