Information Collection

1305.4(l) Eligibility determination records (sample form)

IC 219441 under ICR 201512-0970-004 · OMB 0970-0374.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0374 can be found here:

Documents and Forms

Document Name Document Type
Form 1 1305.4(l) Eligibility determination records (sample form) Form and Instruction
1 Sample eligibility form HS eligibiliy verification form 7-13-15 (3).docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	1305.4(l) Eligibility determination records (sample form)	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
Form and Instruction	1	Sample eligibility form	HS eligibiliy verification form 7-13-15 (3).docx		No		Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,600	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	764,800	764,800
Annual IC Time Burden (Hours)	76,480	76,480
Annual IC Cost Burden (Dollars)	0	0

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.