Information Collection

Insurance Match Debt Inquiry Agreement and Profile

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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	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 %

table that charts list of burden
	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

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.