Appendix A-5S - Receipt of Payment Form (Spanish) - Los Angeles Site

OMB Control No.: 0970-xxxx

Expiration Date: xx/xx/20xx

Appendix A-5S: Receipt of Payment Form (Spanish)—Los Angeles site

Recibo de Pago

Public reporting burden for this collection of information is estimated to average 2 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This information collection is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: Reports Clearance Officer (Attn: OMB/PRA 0970-XXXX), Administration for Children and Families, Department of Health and Human Services, 370 L'Enfant Promenade, S.W., Washington, D.C. 20447.

Poner sus iniciales abajo indica que se le ofreció $40 como compensación de agradecimiento por su tiempo participando en una entrevista para el estudio Estrategias para Sobrellevar la Familia realizado por el Instituto Urbano.

□ Yo acepté la compensación de agradecimiento de $40. □ Yo negué la compensación de agradecimiento de $40.

_________________________________________

Iniciales de Entrevistada

_________________________________________

Fecha

1