Receipt of Payment Form - Los Angeles Site

Understanding the Dynamics of Disconnection from Employment and Assistance

Documents and Forms

Document Name Document Type
Appendix A-5 - Receipt of Payment Form - Los Angeles Site.docx Other-Receipt Payment
Appendix A-5S - Receipt of Payment Form (Spanish) - Los Angeles Site.docx Appendix A-5S - Receipt of Payment Form (Spanish) - Los Angeles Site IC Document

Information Collection (IC) Details

IC Title:	Receipt of Payment Form - Los Angeles Site	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Other-Receipt Payment			Appendix A-5 - Receipt of Payment Form - Los Angeles Site.docx		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: 36	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	36	36
Annual IC Time Burden (Hours)	1	1
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix A-5S - Receipt of Payment Form (Spanish) - Los Angeles Site	Appendix A-5S - Receipt of Payment Form (Spanish) - Los Angeles Site.docx	12/11/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.