Information Collection

SAFETY Act Block Certification

IC 190459 under ICR 201501-1640-002 · OMB 1640-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1640-0001 can be found here:

Documents and Forms

Document Name Document Type
Form DHS Form 10004 SAFETY Act Block Certification Form and Instruction
DHS Form 10004 SAFETY Act Block Certification 10004_SAFETY_Act_Block_Certification _2_.pdf www.safetyact.gov Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SAFETY Act Block Certification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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 and Instruction	DHS Form 10004	SAFETY Act Block Certification	10004_SAFETY_Act_Block_Certification _2_.pdf	www.safetyact.gov	Yes	Yes	Fillable Fileable

Line of Business: Homeland Security

Subfunction: Key Asset and Critical Infrastructure Protection

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	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.