Information Collection

Employer's Statement To Support Claim Under Federal Insurance Contributions Act

IC 130112 under ICR 198109-1545-162 · OMB 1545-0555.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

EMPLOYER'S STATEMENT TO SUPPORT CLAIM UNDER FEDERAL INSURANCE CONTRIBUTIONS ACT

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	5071 PR				No	No
Form	5071,				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	7,500	7,500
Annual IC Time Burden (Hours)	1,500	1,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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