Information Collection

Intended Use Plan

IC 246254 under ICR 202606-0970-008 · OMB 0970-0234.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Intended Use Plan Intended Use Plan	Form
Form 1 Intended Use Plan Intended Use Plan	Form
SSBG_ Intended Use Plan_IUP Instructions.pdf	Instruction
SSBG_ Intended Use Plan_IUP Instructions.pdf	Instruction
1 Intended Use Plan SSBG Intended Use Plan Form - Clean Copy.pdf	Form
1 Intended Use Plan SSBG Intended Use Plan Form - Clean Copy.pdf	Form

IC Title:

Intended Use Plan

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 1397c (To search for a specific CFR, visit the Code of Federal Regulations.)

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
Instruction					Yes	Yes	Printable Only
Form	1				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: 57

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	57	57
Annual IC Time Burden (Hours)	2,280	2,280
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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