Information Collection

Verification of Acceptance Form

IC 240481 under ICR 202303-0915-003 · OMB 0915-0301.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0301 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 8 Verification of Acceptance Form	Form
8 Verification of Acceptance Form Verification of Acceptance Form.doc.docx	Form
8 Verification of Acceptance Form Verification of Acceptance Form.doc.docx	Form

IC Title:

Verification of Acceptance Form

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	8	Verification of Acceptance Form	Verification of Acceptance Form.doc.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
	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	165	165
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.