Information Collection

Agreement and Undertaking

IC 13662 under ICR 202401-1240-001 · OMB 1240-0039.

Documents and Forms

Document Name Document Type
Form OWCP-1 Agreement and Undertaking Form
OWCP-1 Agreement and Undertaking OWCP-1 Current form.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form
OWCP-1 Agreement and Undertaking OWCP-1 Changed name.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Agreement and Undertaking	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 726.110

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	OWCP-1	Agreement and Undertaking	OWCP-1 Changed name.pdf	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

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: 75 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20	3	17
Annual IC Time Burden (Hours)	5	1	4
Annual IC Cost Burden (Dollars)	4	2	2

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.