Information Collection

Confirmation of Interest Form

IC 239776 under ICR 202508-0915-001 · OMB 0915-0140.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Confirmation of Interest Form	Form and Instruction
Form 4 Confirmation of Interest Form Confirmation of Interest Form	Form and Instruction
4 Confirmation of Interest Form Confirmation of Interest (User Guide).pdf	Form and Instruction
4 Confirmation of Interest Form Confirmation of Interest (User Guide).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	4				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 989

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	Previously Approved
Annual Number of Responses for this IC	989	489	500
Annual IC Time Burden (Hours)	198	98	100
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.

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