ETA-9103-4 Planning Form (Health Care Tax Credit)

U.S. Department of Labor OMB Control No. 1205-0439

Employment and Training Administration Expiration Date: 6/30/2010

Planning Form (Health Care Tax Credit)

National Emergency Grant Electronic Application System

All quarterly entries are CUMULATIVE over all previous quarters.

PERFORMANCE FACTOR	PROGRAM YEAR QUARTER
	ADMIN	PROGRAM	QTR1	QTR2	QTR3	QTR4	QTR5	QTR6	QTR7
IMPLEMENTATION SCHECULE
Receiving Supportive Services
Receiving Health Coverage Payments
Total Planned Participants
Supportive Services
Health Coverage Payments
Admin Excluding Premium Payment Processing* cessing
Premium Payment Processing
Other*
Total: Program Management and Oversight
Indirect*
Other*
Total Expenditures

Public Burden Statement:

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control number. Respondents’ obligation to complete this form is required to obtain or retain benefits ( PL: 107-210). Public reporting burden for this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This is public information and there is no expectation of confidentiality. Send comments regarding this burden estimate to the U.S. Department of Labor, Office of National Response, Room C-5311, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0371).

ETA Form 9103-4 (March 2004)

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