Information Collection

Department of State Mentor-Protege Program Application

IC 38774 under ICR 201405-1405-001 · OMB 1405-0161.

Documents and Forms

Document Name Document Type
Form DS-4053 Department of State Mentor-Protege Program Application Form
DS-4053 Department of State Mentor Protégé Program Application Collection Instrument-DS-4053 (7-2014).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Department of State Mentor-Protege Program Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	DS-4053	Department of State Mentor ProtÃ©gÃ© Program Application	Collection Instrument-DS-4053 (7-2014).pdf		Yes	Yes	Fillable Fileable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 98 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20	6	14
Annual IC Time Burden (Hours)	240	-54	294
Annual IC Cost Burden (Dollars)	40	40	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.