Information Collection

Certification of Income Eligibility Upon Enrollment

IC 185376 under ICR 201110-3060-008 · OMB 3060-0819.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	Certification of Income Eligibility Upon Enrollment	Agency IC Tracking Number:	WCB

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 47 CFR Sections 54.400 - 54.417 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

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

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,400	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 10 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1,400	1,400
Annual IC Time Burden (Hours)	112	112
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.