Information Collection

Self-Sufficiency Matrix

IC 264800 under ICR 202502-0970-016 · OMB 0970-0628.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0628 can be found here:

Documents and Forms

Document Name Document Type
Instrument 1 - Self Sufficiency Matrix.pdf Other-Questionnaire
Instrument 1 - Self Sufficiency Matrix.pdf Other-Questionnaire

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Self-Sufficiency Matrix	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Questionnaire			Instrument 1 - Self Sufficiency Matrix.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: 680	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	680	680
Annual IC Time Burden (Hours)	1,020	1,020
Annual IC Cost Burden (Dollars)	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.