Information Collection

Election Form

IC 10015 under ICR 201011-0970-002 · OMB 0970-0196.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0196 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Election Form Form and Instruction
1 Election Form MSFIDM Election Form 2010 PRA_08.03.10.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Election Form	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 and Instruction	1	Election Form	MSFIDM Election Form 2010 PRA_08.03.10.doc		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 122	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 5 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	122	51	71
Annual IC Time Burden (Hours)	61	25	36
Annual IC Cost Burden (Dollars)	2,562	2,562	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.