Information Collection

The Death Compensation Form for the September 11 Victim Compensation Fund and The Personal Injury Compensation Form for the September 11 Victim Compensation Fund

IC 11769 under ICR 200203-1105-001 · OMB 1105-0078.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1105-0078 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	The Death Compensation Form for the September 11 Victim Compensation Fund and The Personal Injury Compensation Form for the September 11 Victim Compensation Fund	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.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SM-003				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	75,000	75,000
Annual IC Cost Burden (Dollars)	500,000	500,000

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.