Information Collection

Disability Accommodation Reimbursement Request Form

IC 221228 under ICR 202602-3045-004 · OMB 3045-0179.

Documents and Forms

Document Name Document Type
AmeriCorps Member Disability Accommodation Off Set Reimbursement Request Form Disability Accommodation Reimbursement Request Form Form and Instruction
AmeriCorps Member Disability Accommodation Off Set Reimb Disability Reimbursement Form ASN_2026-FINAL.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Disability Accommodation Reimbursement Request 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	N/A				Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Community and Regional Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20	0	20
Annual IC Time Burden (Hours)	7	0	7
Annual IC Cost Burden (Dollars)	320	41	279

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.

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