Election Form

Multistate Financial Institution Data Match and Federally Assisted State Transmitted Levy (MSFIDM/FAST Levy)

⚠️ Notice: This information collection may be referencing outdated material.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 MSFIDM Election Form 0970-0196_MSFIDM_Election_Form.docx Form and Instruction

Information Collection (IC) Details

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	MSFIDM Election Form	0970-0196_MSFIDM_Election_Form.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: 15	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	15	-15	30
Annual IC Time Burden (Hours)	8	-7	15
Annual IC Cost Burden (Dollars)	0	-673	673

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.