Information Collection

Disability Accommodation Reimbursement Request Form

IC 221228 under ICR 202602-3045-004 · OMB 3045-0179.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
AmeriCorps Member Disability Accommodation Off Set Reimbursement Request Form Disability Accommodation Reimbursement Request Form	Form and Instruction
AmeriCorps Member Disability Accommodation Off Set Reimb Disability Reimbursement Form ASN_2026-FINAL.docx	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	N/A				Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20	0	20
Annual IC Time Burden (Hours)	7	0	7
Annual IC Cost Burden (Dollars)	320	41	279

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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