Information Collection

Retail Waiver Request Form

IC 263836 under ICR 202312-0584-002 · OMB 0584-0695.

Documents and Forms

Document Name Document Type
Appendix F. FNS Incentive Waiver Request -1.pdf Other-Incentive Waiver Request
Appendix F. FNS Incentive Waiver Request -1.pdf Other-Incentive Waiver Request

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Retail Waiver Request Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Incentive Waiver Request			Appendix F. FNS Incentive Waiver Request -1.pdf		Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	30	30
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.