Information Collection

Claims By Non-federal Law Enforcement Officer And Their Survivors

IC 122187 under ICR 198312-1215-001 · OMB 1215-0116.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0116 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	CLAIMS BY NON-FEDERAL LAW ENFORCEMENT OFFICER AND THEIR SURVIVORS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	ESA	No	No
Form	CA-721,	No	No
Form	CA-722	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 75	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	75	75
Annual IC Time Burden (Hours)	103	103
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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