Information Collection

Annual Certification - Qualified Nonprofit Agency Serving People Who Are Severely Disabled

IC 28982 under ICR 201204-3037-003 · OMB 3037-0002.

Documents and Forms

Document Name Document Type
Form 404 Annual Certification - Qualified Nonprofit Agency Serving People Who Are Severely Disabled Form
404-Instructions 2012.docx Instruction
404 Annual Certification - Qualified Nonprofit Agencies Serv 404 Form 2012.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Annual Certification - Qualified Nonprofit Agency Serving People Who Are Severely Disabled	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	404	Annual Certification - Qualified Nonprofit Agencies Serving People Who Are Severely Disabled	404 Form 2012.docx		Yes	No	Paper Only
Instruction			404-Instructions 2012.docx		Yes	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 550	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	550	-5	555
Annual IC Time Burden (Hours)	3,300	-30	3,330
Annual IC Cost Burden (Dollars)	99,000	-900	99,900

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.