Information Collection

State Agencies

IC 206841 under ICR 202610-0584-001 · OMB 0584-0584.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FNS-843 Report of Disqualification from Participation – Institution and Responsible Principals/Individuals State Agencies	Form
Form FNS-844 eport of Disqualification from Participation – Individually Disqualified Responsible Principal/Individual or Day Care Home Provider State Agencies	Form
FNS-843 Report of Disqualification from Participation – Institut Attachment A Form 843.jpeg	Form
FNS-844 eport of Disqualification from Participation – Individua Attachment B Form 844.jpeg	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

State Agencies

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 7 CFR 226.6(c)(7)(i)

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	FNS-843				Yes	Yes	Fillable Fileable
Form	FNS-844				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records

Title: USDA/FNS-11 Information on Persons Identified as Responsible for Serious Deficiencies, Proposed for Disqualification, or Disqualified to Participate as Principals or Family Day Care Home Operators in

FR Citation: 69 FR 6933

Number of Respondents: 56

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
	Requested	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,568	1,568
Annual IC Time Burden (Hours)	784	784
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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