Information Collection

29; 40-41; 43 - Form MMS-1019 - Insurance Certificate

IC 179367 under ICR 200703-1010-005 · OMB 1010-0106.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1010-0106 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1019 29; 40-41; 43 - Form MMS-1019 - Insurance Certificate	Form
1019 Insurance Certificate Form 1019 exp 10-10.doc www.gomr.mms.gov/homepg/mmsforms/mms1019.PDF	Form

IC Title:

29; 40-41; 43 - Form MMS-1019 - Insurance Certificate

Agency IC Tracking Number:

omm-1010-0106 ext 07

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 30 CFR 253.29; 40-41; 43

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	1019	Insurance Certificate	Form 1019 exp 10-10.doc	http://www.gomr.mms.gov/homepg/mmsforms/mms1019.PDF	Yes	Yes	Fillable Fileable

Line of Business: Energy

Subfunction: Energy Production

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 120

Number of Respondents for Small Entity: 84

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 5 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	14,400	14,400
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.