Information Collection

Notice Of Eligibility, Application And Enrollment Certification

IC 174488 under ICR 198101-2900-032 · OMB 2900-0201.

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Information Collection (IC) Details

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IC Title:	NOTICE OF ELIGIBILITY, APPLICATION AND ENROLLMENT CERTIFICATION	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	22-1990V				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	175,000	-105,884	30,884	250,000
Annual IC Time Burden (Hours)	131,250	-50,000	14,584	166,666
Annual IC Cost Burden (Dollars)	0	0	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.