Information Collection

1305.4(h),(i),, and (j)

IC 219443 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⚠️ Notice: This information collection may be referencing outdated material.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:

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Information Collection (IC) Details

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IC Title:	1305.4(h),(i),, and (j)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 1305

Information Collection Instruments:

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

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	1,600	1,600
Annual IC Time Burden (Hours)	24,000	24,000
Annual IC Cost Burden (Dollars)	0	0

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