Information Collection

Employer's Agreement to Loan Repayment Match/Request for a Waiver of the Loan Repayment Match Form

IC 283507 under ICR 202611-0906-001 · OMB 0906-0082.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Employer’s Agreement to Loan Repayment Match/Request for a Waiver of the Loan Repayment Match Form Employer's Agreement to Loan Repayment Match/Request for a Waiver of the Loan Repayment Match Form	Form
5 Employer’s Agreement to Loan Repayment Match/Request for Employers Agreement.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	5				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: HHS/HRSA/BHW Scholarship and Loan Repayment Program Records

FR Citation: 86 FR 28362

Number of Respondents: 225

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
Annual Number of Responses for this IC	225	225
Annual IC Time Burden (Hours)	225	225
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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