Withdrawl of Application or Declination of Placement Form

Information Collection and record keeping for the timely replacement and release of UC in ORR Care

Documents and Forms

Document Name Document Type
Form 1 Withdrawl of Application or Declination of Placement Form Form and Instruction
1 URM Withdrawal or Declination of Particiapation URM Withdrawal or Declination of Participation.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Withdrawl of Application or Declination of Placement Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	URM Withdrawal or Declination of Particiapation	URM Withdrawal or Declination of Participation.docx		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	10	10
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.