View Information Collection (IC)

View Information Collection (IC)

IC Title:	FCC Form 497 and instructions - individuals or households	Agency IC Tracking Number:	WCB

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 47 CFR 54.400 - 54.707 47 CFR 54.202 47 CFR 54.410(f) 47 CFR 54.416(b) 47 CFR 54.422(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FCC Form 497	Lifeline Worksheet	0819_FCC497_090412.docx		Yes	Yes	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 940	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 35 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	11,280	0	0	0	0	11,280
Annual IC Time Burden (Hours)	28,200	0	0	0	0	28,200
Annual IC Cost Burden (Dollars)	0	0	0	0	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.