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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.