Information Collection

Insurance Match Debt Inquiry Agreement and Profile

IC 233424 under ICR 202411-0970-010 · OMB 0970-0370.

Documents and Forms

Document Name Document Type
Form 1 Insurance Match Debt Inquiry Agreement and Profile Form and Instruction
1 Insurance Match Debt Inquiry Agreement and Profile 0970-0370_Insurance_Match_Debt_Inquiry_Agmt_Profile.pdf Form and Instruction
1 Insurance Match Debt Inquiry Agreement and Profile 0970-0370_Insurance_Match_Debt_Inquiry_Agmt_Profile.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Insurance Match Debt Inquiry Agreement and Profile	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Insurance Match Debt Inquiry Agreement and Profile	0970-0370_Insurance_Match_Debt_Inquiry_Agmt_Profile.pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6	-12	18
Annual IC Time Burden (Hours)	0	-1	1
Annual IC Cost Burden (Dollars)	0	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.