Information Collection

Financial Assistance & Social Services Application

IC 11443 under ICR 201705-1076-003 · OMB 1076-0017.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1076-0017 can be found here:

Documents and Forms

Document Name Document Type
Form 5-6601 Financial Assistance & Social Services Application Form and Instruction
5-6601 Application for Financial Assistance and Social Services Application for Financial Assistance and Social Services_Revised.docx www.bia.gov/WhoWeAre/BIA/OIS/HumanServices/index.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Financial Assistance & Social Services Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 25 CFR 20.300

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5-6601	Application for Financial Assistance and Social Services	Application for Financial Assistance and Social Services_Revised.docx	http://www.bia.gov/WhoWeAre/BIA/OIS/HumanServices/index.htm	Yes	No	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title: BIA-8, Indian Social Services Case Files	FR Citation: 55 FR 34085

Number of Respondents: 240,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 40 %

	Approved	Previously Approved
Annual Number of Responses for this IC	240,000	240,000
Annual IC Time Burden (Hours)	120,000	120,000
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.