Information Collection

Debt Deferral Agreement (state, local and tribal)

IC 44629 under ICR 200608-0575-004 · OMB 0575-0190.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0575-0190 can be found here:

Documents and Forms

Document Name Document Type
MPR Debt Deferral Agreement.doc Other-Exhibit to Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Debt Deferral Agreement (state, local and tribal)	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Exhibit to Instruction			MPR Debt Deferral Agreement.doc		Yes	Yes	Fillable Fileable

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 95 %

	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	25	25
Annual IC Cost Burden (Dollars)	1,250	1,250

Documents for IC

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.