Form S-21C Home Study/Post-Release Service (HS/PRS) Primary Provide

HS/PRS Primary Provider Profile (Form S-21C)
Data Entry Window
OMB 0970-#### [valid through MM/DD/YYYY]

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information
collection is to allow home study and post-release service providers to add identifying information about caseworkers employed by
their organization. Public reporting burden for this collection of information is estimated to average 0.08 hours per response,
including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of
information. This is a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279, and Trafficking Victims Protection
Reauthorization Act, 8 U.S.C. 1232). An agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control
number. If you have any comments on this collection of information please contact UACPolicy@acf.hhs.gov.
UAC-S-21C [Rev. MM/DD/YYYY]

HS/PRS Primary Provider Profile Page

OMB 0970-#### [valid through MM/DD/YYYY]
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow home study and post-release service providers to add identifying information about caseworkers employed by their
organization. Public reporting burden for this collection of information is estimated to average 0.08 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a
mandatory collection of information (Homeland Security Act, 6 U.S.C. 279, and Trafficking Victims Protection Reauthorization Act, 8 U.S.C. 1232). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to
the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information please contact UACPolicy@acf.hhs.gov.
UAC-S-21C [Rev. MM/DD/YYYY]