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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

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.