Information Collection

Annuity Broker Qualification Declaration Form

IC 11774 under ICR 200608-1105-001 · OMB 1105-0080.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1105-0080 can be found here:

Documents and Forms

Document Name Document Type
Form CIV 1105-0080 Annuity Broker Qualification Declaration Form Form and Instruction
CIV 1105-0080 Annuity Broker Qualification Declaration Form Annuity Broker Qualification Declaration Form (Oct 06).pdf www.usdoj.gov/civil/forms/forms.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Annuity Broker Qualification Declaration Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 and Instruction	CIV 1105-0080	Annuity Broker Qualification Declaration Form	Annuity Broker Qualification Declaration Form (Oct 06).pdf	http://www.usdoj.gov/civil/forms/forms.htm	Yes	No	Printable Only

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	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	400	400
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	20,000	20,000

Documents for IC

Title	Document	Date Uploaded
No associated records found

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