Information Collection

Certification of Compliance with the Statutory Eligibility Requirements of the Violence Against Women Act as Amended

IC 12639 under ICR 200608-1122-001 · OMB 1122-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1122-0001 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1122-0001 Certification of Compliance with the Statutory Eligibility Requirements of the Violence Against Women Act as Amended	Form and Instruction
1122-0001 Certification of Compliance with the Statutory Eligibili Finalcertificationform2005_OVW.doc	Form and Instruction

IC Title:

Certification of Compliance with the Statutory Eligibility Requirements of the Violence Against Women Act as Amended

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 28 CFR 90

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1122-0001	Certification of Compliance with the Statutory Eligibility Requirements of the Violence Against Women Act as Amended, STOP Formulat Grant Program	Finalcertificationform2005_OVW.doc	gms.gov	Yes	Yes	Fillable Fileable

Line of Business: Law Enforcement

Subfunction: Citizen Protection

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	56	56
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.