U.S. DEPARTMENT OF JUSTICE, INSURANCE-RELATED CRIMINAL REFERRAL FORM

ICR 199208-1105-001

OMB: 1105-0054

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
1105-0054 199208-1105-001
Historical Active
DOJ/LA
U.S. DEPARTMENT OF JUSTICE, INSURANCE-RELATED CRIMINAL REFERRAL FORM
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 08/17/1992
Retrieve Notice of Action (NOA) 08/05/1992
This form must be revised to provide a standard PRA burden statement, an OMB approval number and an expiration date before the Department of Justice makes it available to the public.
  Inventory as of this Action Requested Previously Approved
08/31/1995 08/31/1995
200 0 0
304 0 0
0 0 0

THE FORM WILL BE USED TO ENCOURAGE STATE INSURANCE DEPARTMENTS TO REFE SIGNIFICANT CRIMINAL ACTIVITY FOR FEDERAL PROSECUTION. IT WILL ENABLE THE DEPARTMENT OF JUSTICE TO ENSURE THAT ALL CASES ARE BEING INVESTIGATED APPOPRIATELY AND THAT ALL RELATED INVESTIGATIONS ARE COORDINATED.

None
None


No

1
IC Title Form No. Form Name
U.S. DEPARTMENT OF JUSTICE, INSURANCE-RELATED CRIMINAL REFERRAL FORM

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 200 0 0 200 0 0
Annual Time Burden (Hours) 304 0 0 304 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
08/05/1992


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