United States Department of Veterans Affairs
Homeless Veterans

Contact Information form

  Please fill out contact information:
  OMB Number: 2900-0554
  Estimated Burden: 2 minutes
  Expiration Date: September 30, 2006
Name of Agency:
Last name: *
First name: *
Middle initial:
Title:
Address: *
City: *
State: *
Zip: *
Type of Request *
Phone number:
Email:
   * Required
     
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. The public reporting burden for this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. This information will be used to notify the Council of Network Homeless Coordinators (CNHC) of the organizations in their area who are interested in applying for the Grant and Per Diem Program. This contact information helps CNHC members build relationships with applying organizations and assist them with specific information they will need when filing out the application.