Proof of Loss Form - Cerro Grande Fire Assistance Claims

ICR 200103-3067-002

OMB: 3067-0282

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
3067-0282 200103-3067-002
Historical Active 200009-3067-001
FEMA
Proof of Loss Form - Cerro Grande Fire Assistance Claims
Extension without change of a currently approved collection   No
Regular
Approved without change 05/16/2001
Retrieve Notice of Action (NOA) 03/20/2001
  Inventory as of this Action Requested Previously Approved
05/31/2004 05/31/2004 05/31/2001
18,000 0 18,000
405,000 0 405,000
0 0 0

The Cerro Grande Fire Assistance Act (PL 106-246) establishes the process to receive, evaluate, determine and settle claims against the United States by victims of the Cerro Grande (Los Alamos) New Mexico fire in May 2000. Completion of the Proof of Loss form is required by FEMA regulations 44 CFR 295.5 and 295.30 and must provide a specific desription of each claimant's losses and the value of the loss, under penalty of perjury and subject to the provisions of U.S.C. section 1001 relating to false statements.

None
None


No

1
IC Title Form No. Form Name
Proof of Loss Form - Cerro Grande Fire Assistance Claims CG-2

  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 18,000 18,000 0 0 0 0
Annual Time Burden (Hours) 405,000 405,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
03/20/2001


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