Information Collection

Beneficiary Report - Beneficiaries

IC 273178 under ICR 202412-0970-007 · OMB 0970-0642.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0642 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Instrument 2 - Beneficiary Report.xlsx	Other-Report
Instrument 2 – Beneficiary Report (CLEAN Version).docx	Other-Report

IC Title:

Beneficiary Report - Beneficiaries

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
Other-Report					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: 64,000

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	42,667	42,667
Annual IC Time Burden (Hours)	3,556	3,556
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.

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