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

ICR 200208-1105-002

OMB: 1105-0078

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
1105-0078 200208-1105-002
Historical Active 200203-1105-001
DOJ/LA
The Death Compensation form for the September 11 Victim Compensation Fund and The Personal Injury Compensation Form for the September 11 Victim Compensation Fund
Extension without change of a currently approved collection   No
Regular
Approved without change 10/25/2002
Retrieve Notice of Action (NOA) 08/14/2002
  Inventory as of this Action Requested Previously Approved
10/31/2005 10/31/2005 10/31/2002
5,000 0 5,000
75,000 0 75,000
500,000 0 500,000

Physically injured victims as a result of the terrorist-related attacks of September 11, 2001 will use the Injury Compensation Form and Personal Representatives of those killed as a result of September 11 will use the Death Compensation Form. Both forms will be used to provide information needed to determine eligibility for the program and to calculate compensation awards.

None
None


No

  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 5,000 5,000 0 0 0 0
Annual Time Burden (Hours) 75,000 75,000 0 0 0 0
Annual Cost Burden (Dollars) 500,000 500,000 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.
08/14/2002


© 2024 OMB.report | Privacy Policy