Information Collection

Eligibility Questionnaire For Havana Act Payments

IC 259317 under ICR 202610-0690-001 · OMB 0690-0037.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CD-350 ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS	Form and Instruction
Form CD-350 CD-350 Final 508 Compliant Havana Act ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS	Form
RELATIONSHIP DOCS - HAVANA Act Payments Collection.docx	Instruction
CD-350 ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS CD-350 FINAL 508 Compliant 10.29.26 Havana Act.pdf	Form and Instruction
CD-350 CD-350 Final 508 Compliant Havana Act CD-350 FINAL 508 Compliant 10.29.26 Havana Act.pdf	Form

IC Title:

ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CD-350	No		Fillable Printable
Instruction		Yes	Yes	Fillable Printable
Form	CD-350	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Survivor Compensation

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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	20	20
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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