Information Collection

Crime Victim Compensation State Certification Form

IC 12436 under ICR 199902-1121-001 · OMB 1121-0170.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1121-0170 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	Crime Victim Compensation State Certification Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

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	OJP-FORM-7390/5				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	52	52
Annual IC Cost Burden (Dollars)	1,000	1,000

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.