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Federal forms, ICRs, and supporting documents

Information Collection Request

September 11th Victim Compensation Fund Claimant Registration Form

ICR 201201-1105-003 · OMB 1105-0092 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form XXXX Deceased Compensatin Form Form and Instruction New Repair queued
Form XXXX Deceased Eligibility Form Form and Instruction New Repair queued
Form XXXX Personal Injury Compensation Form Form and Instruction New Repair queued
Form XXXX Personal Injury Eligibility Form Form and Instruction New Repair queued
83i PRA_092611.pdf Supplementary Document Uploaded 2011-09-26 Available
1105-0092_Supporting_Statement_PRA_--_Eligibility_and_Compensation_Form_-_updated_6_18_12.doc Supporting Statement A Uploaded 2012-06-18 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
202770 Deceased Compensatin Form Form and Instruction New
202769 Deceased Eligibility Form Form and Instruction New
202768 Personal Injury Compensation Form Form and Instruction New
202767 Personal Injury Eligibility Form Form and Instruction New
199461 September 11th Victim Compensation Registration Form Other-Screen Shots Removed
ICR Details
1105-0092 201201-1105-003
Historical Active 201201-1105-002
DOJ/LA
September 11th Victim Compensation Fund Claimant Registration Form
Extension without change of a currently approved collection   No
Regular
Approved without change 07/07/2012
Retrieve Notice of Action (NOA) 04/18/2012
  Inventory as of this Action Requested Previously Approved
07/31/2015 36 Months From Approved 07/31/2012
70,000 0 70,000
700,000 0 700,000
0 0 0
Under the James Zadroga September 11 Health and Compensation Act of 2010 (P.L. 111-347), the Department of Justice would request biographical information and limited information regarding eligibility for the September 11th Victim Compensation Fund from potential claimants in order to begin the process of determining whether claimants will be eligible for compensation from the Fund.
PL: Pub.L. 111 - 347 404 Name of Law: James Zadroga 9/11 Health and Compensation Act of 2010
  
PL: Pub.L. 111 - 347 404 Name of Law: James Zadroga 9/11 Health and Compensation Act of 2010
Not associated with rulemaking
  77 FR 5056 02/01/2012
77 FR 21107 04/09/2012
No
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 70,000 70,000 0 0 0 0
Annual Time Burden (Hours) 700,000 700,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
There is no burden change. Burden is broken down by IC for this ICR, consistent with previous terms of clearance.
No
No
No
No
No
Uncollected
Jonathan Olin 202 514-5585
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
04/18/2012