Information Collection

State, Local or Tribal Governments

IC 241111 under ICR 202504-3060-005 · OMB 3060-1271.

Documents and Forms

Document Name Document Type
Form FCC Form 461 Request for Services State, Local or Tribal Governments Form
Form FCC Form 462 Request for Funding State, Local or Tribal Governments Form
Form FCC Form 463 Description of Request for Funding Disbursement State, Local or Tribal Governments Form
Sample Letter of Authorization.pdf Other-COVID-19, Telehealth Program,
Sample Letter of Authorization.pdf Other-COVID-19, Telehealth Program,
FCC Form 461 Request for Services FCC Form 461 - Request for Services (Sept 2024).pdf Form
FCC Form 461 Request for Services FCC Form 461 - Request for Services (Sept 2024).pdf Form
FCC Form 462 Request for Funding FCC Form 462 - Request for Funding (Nov 2023).pdf Form
FCC Form 462 Request for Funding FCC Form 462 - Request for Funding (Nov 2023).pdf Form
FCC Form 463 Description of Request for Funding Disbursement FCC Form 463 - Description of Request for Funding Disbursement (Nov 2023).pdf Form
FCC Form 463 Description of Request for Funding Disbursement FCC Form 463 - Description of Request for Funding Disbursement (Nov 2023).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State, Local or Tribal Governments	Agency IC Tracking Number:	WCB

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-COVID-19, Telehealth Program, LOA			Sample Letter of Authorization.pdf	Yes	Yes	Fillable Printable
Form	FCC Form 461	Request for Services	FCC Form 461 - Request for Services (Sept 2024).pdf	Yes	Yes	Fillable Fileable Signable
Form	FCC Form 462	Request for Funding	FCC Form 462 - Request for Funding (Nov 2023).pdf	Yes	Yes	Fillable Fileable Signable
Form	FCC Form 463	Description of Request for Funding Disbursement	FCC Form 463 - Description of Request for Funding Disbursement (Nov 2023).pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,403	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	11,518	11,518
Annual IC Time Burden (Hours)	65,929	65,929
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].