Application for Digital-to-Analog Converter Box Coupons for Nursing Home Residents

Documents and Forms

Document Name Document Type
Application for Digital-to-Analog Converter Box Coupons for Nursing Home Residents Form and Instruction
Application for Converter Box Coupons for Nursing Home R 0660.Draft Nursing Home Coupon Application.Rev.090908.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Digital-to-Analog Converter Box Coupons for Nursing Home Residents	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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	None	Application for Converter Box Coupons for Nursing Home Residents	0660.Draft Nursing Home Coupon Application.Rev.090908.doc		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 414,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	414,000	414,000
Annual IC Time Burden (Hours)	138,000	138,000
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.