Information Collection

Provider Relief Fund (PRF) Questioned Cost Attestation Form

IC 264092 under ICR 202505-0906-003 · OMB 0906-0083.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Provider Relief Fund (PRF) Questioned Cost Attestation Form	Form and Instruction
Form 3 Questioned Cost Attestation Form Provider Relief Fund (PRF) Questioned Cost Attestation Form	Form and Instruction
3 Questioned Cost Attestation Form Questioned Cost Attestation Form_Final.docx	Form and Instruction
3 Questioned Cost Attestation Form Questioned Cost Attestation Form_Final.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

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	3				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	70,000	70,000
Annual IC Time Burden (Hours)	350,000	350,000
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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