Provider Relief Fund (PRF) Questioned Cost Attestation Form

COVID–19 Provider Relief Programs Single and Commercial Audits and Delinquent Audit Reporting Submission Activities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0083 can be found here:

Documents and Forms

Document Name Document Type
Form 3 Provider Relief Fund (PRF) Questioned Cost Attestation Form Form and Instruction
3 Provider Relief Fund (PRF) Questioned Cost Attestation F Questioned Cost Attestation Form_V2.docx Form and Instruction
3 Provider Relief Fund (PRF) Questioned Cost Attestation F Questioned Cost Attestation Form_Final .docx Form and Instruction

Information Collection (IC) Details

IC Title:	Provider Relief Fund (PRF) Questioned Cost Attestation Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

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	3	Provider Relief Fund (PRF) Questioned Cost Attestation Form	Questioned Cost Attestation Form_Final .docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,000	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
Annual Number of Responses for this IC	70,000	70,000
Annual IC Time Burden (Hours)	350,000	350,000
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.