Information Collection

Experience Rating Report

IC 13005 under ICR 201807-1205-004 · OMB 1205-0164.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0164 can be found here:

Documents and Forms

Document Name Document Type
Form ETA 204 Experience Rating Report Form and Instruction
ETA 204 Experience Rating Report SectionII_FundManagementActivity_ETA-204.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Experience Rating Report	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 and Instruction	ETA 204	Experience Rating Report	SectionII_FundManagementActivity_ETA-204.docx		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	53	53
Annual IC Time Burden (Hours)	27	27
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.