2008 17f-2(e) 83-I

PAPERWORK REDUCTION ACT SUBMISSION WORKSHEET

Part II: Information Collection Detail

Please read the instructions before using this worksheet. This form is not intended for submission to OIRA. This worksheet is intended to help users transition between the paper 83 system and use of the RISC/OIRA Consolidated Information System (ROCIS) ICR Module for submitting PRA requests to OIRA. For additional assistance, contact your agency's Paperwork Clearance Officer. To obtain access rights to ROCIS, contact the Regulatory Information Service Center at (202) 482-7340.

1. Agency:

3235 SEC

Division/Office

TM-SEC

2.

Agency IRC Tracking Number:

270-37

3.

Title:

Exchange Act Rule 17f-2(e), Notice pursuant to Rule 17f-2(2) (17 CFR 240.17f-2(e). 

4.

Is this a request for a Generic Clearance?

If Yes, enter Generic Clearance Budget Requested Annual Number of Responses, Annual Time Burden, and Annual Cost Burden under ICR Summary of Burden (field) 16 below.

Yes No

5.

Type of Information Collection (check one):

Extension without change of a currently approved collection Revision of a currently approved collection Nonmaterial or non-substantive change to a currently approved collection

6.

Type of review requested (check one):

7. Requested expiration date (check one):

a.

Regular (Must be checked if this request is for a Generic Clearance)

a.

Three years from approval date

b.

Six Months from approval date (Maximum for Emergency reviews)

b.

Emergency - Approval requested by:

     

(M/D/YYYY)

c.

Other (specify the date below)

c.

Delegated

(Only fill this out if you chose letter c. above)

If Emergency, please attach justification.

Specify:

  

/

  

or Number of Months From Approval Date 

     

MM

YY

     

8.

Does this ICR contain surveys, censuses, or employ statistical methods?

Yes (Attach Part B of Supporting Statement) No

9.

Does the Supporting Statement serve as a Joint ICR and Privacy Impact Assessment per OMB Memorandum 03-22 (http://www.whitehouse.gov/omb/memoranda/m03-22.html), Section II.D.?

Yes No

10.

Agency Contact:

First Name

Thomas

Last Name

Etter

Agency

SEC

Telephone

202-551-5513

11.

Abstract (4000 characters maximum):

Rule 17f-2(e), adopted November 18, 1982, effective November 22, 1982 (see 47 FR 54060), requires members of national securities exchanges, brokers, dealers, registered transfer agents, and clearing agencies claiming examption from the fingerprinting requirements of Rule 17f-2 to prepare and maintain a statement supporting their claim for exemption.

12.

Authorizing Statute(s): Only fill if this is associated with a rulemaking or ICR

a.

US Code

15

USC

78q(f)2)(e)

Name of Law:

Section 17(f)(2) of the Securities Exchange Act of 1934.

US Code

     

USC

     

Name of Law:

     

US Code

     

USC

     

Name of Law:

     

US Code

     

USC

     

Name of Law:

     

Only fill if applicable

b.

PL

Pub.L.

94

-

29

Sec

324

Name of Law:

Securities Reform Act of 1975

Only fill if applicable

c.

Statute at Large

     

USC

     

Name of Statute:

     

Only fill if applicable

d.

EO

EO

     

Name /Subject of EO:

     

13

Associated Rulemaking Information

RIN (Put Primary RIN here and Secondary RIN[s] in the SS):

Stage of Rulemaking (check one):

Federal Register Citation:

Citation Date:

 

 

 

 



 

 

 

 

Proposed Rule

47

FR

54060

December 1, 1982

(M/D/YYYY)

Interim Final or Final Rule

Not associated with rulemaking

For a Proposed Rule, OMB will not consider an ICR complete until the Notice of Proposed Rulemaking has been published. For a Final Rule, please put the ICR reference number for the ICR reviewed at the proposed rule stage in Box 4. For ICRs associated with Interim Final or Final rules that are not significant under EO 12866, please attach a draft of the Federal Register document.

14.

Federal Register Notices & Comments

Federal Register Citation:

Citation Date:

Did the Agency receive public comments on this ICR?

60-day Notice:

     

FR

     

     

(M/D/YYYY)

Yes No

30-day Notice:

     

     

     

(M/D/YYYY)

Unless submitted as an Emergency or Associated with Rulemaking, OMB will not consider an ICR complete until the 30-day notice has been published.

15.

Annual Cost to Federal Government: $

0.00

16

Add/Edit Information Collections (Go to Part II: Information Collection Detail on page three of this template)

17.

ICR Summary of Burden: (For this part you need to complete either Part IIIa: Information Collection Burden Worksheet or Part IIIb: Alternate Information Collection Burden Worksheet, depending on your ICR type – on pages 7 and 8 of this template.)

18.

Citations for New Statutory Requirements: (Required if any change in burden is a Program Change Due to New Statute.)

a.

US Code:

     

USC

     

Name of Law:

     

US Code:

     

USC

     

Name of Law:

     

US Code:

     

USC

     

Name of Law:

     

US Code:

     

USC

     

Name of Law:

     

Only fill if applicable

b.

PL:

Pub.L.

     

-

     

Sec

     

Name of Law:

     

Only fill if applicable

c.

Statute at Large:

     

USC

     

Name of Statute:

     

Only fill if applicable

d.

EO:

EO

     

Name /Subject of EO:

     

19.

Burden increases because of Program Change due to Agency Discretion

Burden decreases because of Program Change due to Agency Discretion

20.

Add/Edit Supporting Statement and Other Documents (Note: The Clearance Officer will upload the Supporting Statement in ROCIS).

a. Supplementary Documents (only fill if applicable – this could include a justification for change, an old rule or new rule that has been proposed, the previous collection instrument, etc.)

Title

Document Type (Select One)

Document Date (M/D/YYY)

Document File

     

     

     

     

     

     

     

     

     

     

     

     

Please prepare this sheet for each Information Collection covered by the ICR. You may aggregate requirements as necessary, but please only aggregate forms that are similar by collection frequency and respondent base. For Information Collections not in the Code of Federal Regulations, you will be prompted to upload an electronic copy of each instrument or document in question 6. Note: When you click on Add/Edit Information Collections in ROCIS (#16 above) you will be taken to the screen below. If you click on an existing form (for example Form 11-K) or if you click on “Add IC” you will be taken to Part II: Information Collection Detail to fill out the fields below.

1.

IC Title:

2.

Agency IC Tracking Number

Exchange Act Rule 17f-2(e), Notice pursuant to Rule 17f-2 (17 CFR 240.17f-2(e))

270-37

3.

Is this a Common Form?

Yes No

4.

Obligation to respond (select one):

5.

CFR Citation:

Title

Part

17

CFR

240.17f-2(e)

  

CFR

     

  

CFR

     

  

CFR

     

6.

Information Collection Instruments

Instrument Filename

Document Type (Select One)

Form No.

Form Name

Available Electronically?

If Yes, Can Be Submitted Electronically?

Electronic Capability (Select One)

URL (Required Unless Not Electronic)

     

     

     

Yes No

Yes No

     

     

     

     

Yes No

Yes No

     

     

     

     

Yes No

Yes No

     

     

     

     

Yes No

Yes No

     

7.

Federal Enterprise Architecture Business Reference Module Line of Business: See the Federal Enterprise Architecture Program Management Office <http://www.feapmo.gov/> for the Business Reference Model categories and definitions. Services for Citizens

Refer to the PMP Navigation Bar for FEA BRM definitions Subfunction:

Economic Development

Business and Industry Development Financial Sector Oversight None

Education

Elementary, Secondary, and Vocational Education None

International Affairs and Commerce

Foreign Affairs None

Litigation and Judicial Activities

Judicial Hearing Legal Defense Legal Investigation Legal Prosecution and Litigation Resolution Facilitation None

Mode of Delivery

Knowledge Creation and Management

General Purpose Data and Statistics Advising and Consulting None

Regulatory Compliance and Enforcement

Inspections and Auditing Standard Setting/Reporting Guideline Development Permits and Licensing None

Federal Financial Assistance

Direct Transfers to Individuals None

Support Delivery of Services

Controls and Oversight

Corrective Action Program Monitoring Program Evaluation None

Internal Risk Management and Mitigation

Contingency Planning Continuity of Operations Service Recovery None

Legislative Relations

Legislative Tracking Legislative Testimony Proposal Development Congressional Liaison Operations None

Public Affairs

Customer Services Official Information Dissemination Public Relations None

Regulatory Development

Public Comment Tracking Rule Publication Policy and Guidance Development Regulatory Creation None

Revenue Collection

Debt Collection User Fee Collection None

8.

Privacy Act System of Records (if applicable)

Federal Register Citation:

Title:

     

  

FR

     

9.

Respondents:

a.

Number of Respondents:

     

b.

Number of Respondents who are Small Entities:

     

c.

Affected public (check one)

Federal Government

Individuals or Households

Private Sector

For Private Sector, check all that apply below: Business or other for-profits Not-for-profit institutions Farms

State, Local, or Tribal Governments

d.

Percent of Respondents Reporting Electronically: (%)

0%

10.

Annual IC Burden: (To be calculated by ROCIS; Please complete Part IIIa or IIIb worksheet if this ICR reflects a request to change burden of IC=s from the Approved Burden (in current Inventory). Select appropriate IC Burden Worksheet)

Please use this sheet to gather information about burden for each Information Collection in the ICR. ROCIS will use the information on this sheet to calculate total burden for the IC and the ICR. If this ICR is an extension and you are requesting no change in burden, you may use Part IIIb instead of this sheet.

1.

Enter Number of Respondents (Part II, Question 9a):

75

respondents

2.

Per Time Period: How often on average will each respondent respond to the Information Collection?

1

Number of Responses per Respondent 

per (Select one appropriate time period for this collection)

Annual Frequency

Time Period

Conversion Factor

8,736

a.

Hour (24 per day, 7 days a week)

8,736 per year

2,080

b.

Business Hour (8 per day, 5 days a week)

2,080 per year

 365

c.

Day (7 per week)

365 per year

 260

d.

Business Day (5 per week)

260 per year

 52

e.

Week

52 per year

 12

f.

Month

12 per year

 1

g.

Year

1 per year

 0.01

h.

Decade

0.1 per year

 4

i.

Quarterly

4 per year

 2

j.

Semi-annually

2 per year

 0.50

k.

Biennially (every other year)

0.5 per year

3.

Annual Frequency: Multiply Number of Responses per Respondent in Question 2 by the Conversion Factor next to time period you selected.

1

times per year per respondent

Enter the calculated Annual Frequency figure for your selected Time Period

4.

Annual Number of Responses: Multiply line 1 by line 3.

 75

responses per year

5.

Type of Collection and Burden:

a.

How many hours are required to complete the collection per response? Estimated cost per Response? Indicate how much of the burden of this IC is due to reporting, due to record keeping, or due to third-party disclosures.

Time Per Response

Cost per Response

Frequency of Reporting:

Since ROCIS will calculate in hours only, please round up or down any fractional hours from your time.

Reporting

i.

     

Hours

v.

$

     

Biennially Decade Monthly Once Semi-annually Annually

Daily Hourly On Occasion Quarterly Weekly

Record keeping

ii.

1.00

Hours

vi.

$

20.00

Third party disclosure

iii.

     

Hours

vii.

$

     

Total

iv.

 1.00

Hours

viii.

$

 20.00

b.

ROCIS will calculate Annual Time Burden and Annual Cost Burden based on 5.a. The sum of these three must equal the annual burden of the IC, Part II, number 10.

	Annual Time Burden				Annual Cost Burden
Reporting	i.	 0.00	Hours	(4 X 5.a.i.)	v.	$	 0.00	(4 X 5a.v)
Record keeping	ii.	 75.00	Hours	(4 X 5.a.ii.)	vi.	$	1,500.00	(4 X 5a.vi)
Third party disclosure	iii.	 0.00	Hours	(4 X 5.a.iii.)	vii.	$	 0.00	(4 X 5a.vii)
Total	iv.	 75	Hours	(4 X 5a.iv)	viii.	$	1,500.00	(4 X 5a.viii)

6.

Complete the following table. Use the OMB Inventory of currently approved information collections to complete the Approved column. The difference between Requested and Approved in each row must be the sum of the four categories of changes. ROCIS will help you fill this table in by putting any missing difference in Program Change Due to Agency Discretion. You may then reenter in any of the four middle columns as applicable. ROCIS will complete the table in Part II, Question 10 from this input.

		Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Violation of the PRA	Approved (In current inventory)
a.	Annual Number of Responses for this IC	75 (Line 4)	00.00000.5one hl	     	     	     	     
b.	Annual IC Time Burden	 75 hours (Line 5b iv)	      hours	      hours	      hours	      hours	      hours
c.	Annual IC Cost Burden	$ 1,500.00 (Line 5b viii)	$      	$      	$      	$      	$      

Please use this sheet to gather information about burden for each Information Collection in the ICR. ROCIS will use the information on this sheet to calculate total burden for the IC and the ICR. If this ICR is an extension and you are requesting no change in burden, you may use Part IIIb instead of this sheet.

1.

Enter Number of Respondents (Part II, Question 9a):

     

respondents

2.

Per Time Period: How often on average will each respondent respond to the Information Collection?

     

Number of Responses per Respondent 

per (Select one appropriate time period for this collection)

Annual Frequency

Time Period

Conversion Factor

 0

a.

Hour (24 per day, 7 days a week)

8,736 per year

 0

b.

Business Hour (8 per day, 5 days a week)

2,080 per year

 0

c.

Day (7 per week)

365 per year

 0

d.

Business Day (5 per week)

260 per year

 0

e.

Week

52 per year

 0

f.

Month

12 per year

 0

g.

Year

1 per year

 0.00

h.

Decade

0.1 per year

 0

i.

Quarterly

4 per year

 0

j.

Semi-annually

2 per year

 0.00

k.

Biennially (every other year)

0.5 per year

3.

Annual Frequency: Multiply Number of Responses per Respondent in Question 2 by the Conversion Factor next to time period you selected.

     

times per year per respondent

Enter the calculated Annual Frequency figure for your selected Time Period

4.

Annual Number of Responses: Multiply line 1 by line 3.

 0

responses per year

5.

Type of Collection and Burden:

a.

How many hours are required to complete the collection per response? Estimated cost per Response? Indicate how much of the burden of this IC is due to reporting, due to record keeping, or due to third-party disclosures.

Time Per Response

Cost per Response

Frequency of Reporting:

ROCIS will calculate in hours if you wish to enter time per response in seconds or minutes.

Reporting

i.

     

Hours

v.

$

     

Biennially Decade Monthly Once Semi-annually Annually

Daily Hourly On Occasion Quarterly Weekly

Record keeping

ii.

     

Hours

vi.

$

     

Third party disclosure

iii.

     

Hours

vii.

$

     

Total

iv.

 0.00

Hours

viii.

$

 0.00

b.

ROCIS will calculate Annual Time Burden and Annual Cost Burden based on 5.a. The sum of these three must equal the annual burden of the IC, Part II, number 10.

	Annual Time Burden				Annual Cost Burden
Reporting	i.	 0.00	Hours	(4 X 5.a.i.)	v.	$	 0.00	(4 X 5a.v)
Record keeping	ii.	 0.00	Hours	(4 X 5.a.ii.)	vi.	$	 0.00	(4 X 5a.vi)
Third party disclosure	iii.	 0.00	Hours	(4 X 5.a.iii.)	vii.	$	 0.00	(4 X 5a.vii)
Total	iv.	 0	Hours	(4 X 5a.iv)	viii.	$	 0.00	(4 X 5a.viii)

6.

Complete the following table. Use the OMB Inventory of currently approved information collections to complete the Approved column. The difference between Requested and Approved in each row must be the sum of the four categories of changes. ROCIS will help you fill this table in by putting any missing difference in Program Change Due to Agency Discretion. You may then reenter in any of the four middle columns as applicable. ROCIS will complete the table in Part II, Question 10 from this input.

		Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Violation of the PRA	Approved (In current inventory)
a.	Annual Number of Responses for this IC	0 (Line 4)	     	     	     	     	     
b.	Annual IC Time Burden	 0 hours (Line 5b iv)	      hours	      hours	      hours	      hours	      hours
c.	Annual IC Cost Burden	$  0.00 (Line 5b viii)	$      	$      	$      	$      	$      

Please use this sheet to gather information about burden for each Information Collection in the ICR. ROCIS will use the information on this sheet to calculate total burden for the IC and the ICR. If this ICR is an extension and you are requesting no change in burden, you may use Part IIIb instead of this sheet.

1.

Enter Number of Respondents (Part II, Question 9a):

     

respondents

2.

Per Time Period: How often on average will each respondent respond to the Information Collection?

     

Number of Responses per Respondent 

per (Select one appropriate time period for this collection)

Annual Frequency

Time Period

Conversion Factor

 0

a.

Hour (24 per day, 7 days a week)

8,736 per year

 0

b.

Business Hour (8 per day, 5 days a week)

2,080 per year

 0

c.

Day (7 per week)

365 per year

 0

d.

Business Day (5 per week)

260 per year

 0

e.

Week

52 per year

 0

f.

Month

12 per year

 0

g.

Year

1 per year

 0.00

h.

Decade

0.1 per year

 0

i.

Quarterly

4 per year

 0

j.

Semi-annually

2 per year

 0.00

k.

Biennially (every other year)

0.5 per year

3.

Annual Frequency: Multiply Number of Responses per Respondent in Question 2 by the Conversion Factor next to time period you selected.

     

times per year per respondent

Enter the calculated Annual Frequency figure for your selected Time Period

4.

Annual Number of Responses: Multiply line 1 by line 3.

 0

responses per year

5.

Type of Collection and Burden:

a.

How many hours are required to complete the collection per response? Estimated cost per Response? Indicate how much of the burden of this IC is due to reporting, due to record keeping, or due to third-party disclosures.

Time Per Response

Cost per Response

Frequency of Reporting:

ROCIS will calculate in hours if you wish to enter time per response in seconds or minutes.

Reporting

i.

     

Hours

v.

$

     

Biennially Decade Monthly Once Semi-annually Annually

Daily Hourly On Occasion Quarterly Weekly

Record keeping

ii.

     

Hours

vi.

$

     

Third party disclosure

iii.

     

Hours

vii.

$

     

Total

iv.

 0.00

Hours

viii.

$

 0.00

b.

ROCIS will calculate Annual Time Burden and Annual Cost Burden based on 5.a. The sum of these three must equal the annual burden of the IC, Part II, number 10.

	Annual Time Burden				Annual Cost Burden
Reporting	i.	 0.00	Hours	(4 X 5.a.i.)	v.	$	 0.00	(4 X 5a.v)
Record keeping	ii.	 0.00	Hours	(4 X 5.a.ii.)	vi.	$	 0.00	(4 X 5a.vi)
Third party disclosure	iii.	 0.00	Hours	(4 X 5.a.iii.)	vii.	$	 0.00	(4 X 5a.vii)
Total	iv.	 0	Hours	(4 X 5a.iv)	viii.	$	 0.00	(4 X 5a.viii)

6.

Complete the following table. Use the OMB Inventory of currently approved information collections to complete the Approved column. The difference between Requested and Approved in each row must be the sum of the four categories of changes. ROCIS will help you fill this table in by putting any missing difference in Program Change Due to Agency Discretion. You may then reenter in any of the four middle columns as applicable. ROCIS will complete the table in Part II, Question 10 from this input.

		Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Violation of the PRA	Approved (In current inventory)
a.	Annual Number of Responses for this IC	0 (Line 4)	     	     	     	     	     
b.	Annual IC Time Burden	 0 hours (Line 5b iv)	      hours	      hours	      hours	      hours	      hours
c.	Annual IC Cost Burden	$  0.00 (Line 5b viii)	$      	$      	$      	$      	$      

If this ICR is an extension and you are requesting no change in total burden, you may use this worksheet instead of Part IIIa for every information collection in the ICR. Use this sheet gather information about burden for each Information Collection in the ICR. ROCIS will use the information on this sheet to calculate total burden for the IC and the ICR.

1.

Annual Number of Responses:

     

responses per year

2.

Type of Collection: Indicate how much of the burden of this IC is due to reporting, due to record keeping, or due to third-party disclosures. The sum of these three must equal the annual burden of the IC.

Time Per Response

Cost per Response

Frequency of Reporting:

Reporting

a.

     

Hours

e.

$

     

Biennially Decade Monthly Once Semi-annually Annually

Daily Hourly On Occasion Quarterly Weekly

Record keeping

b.

     

Hours

f.

$

     

Third party disclosure

c.

     

Hours

g.

$

     

Total

d.

 0.00

Hours

h.

$

 0.00

3.

Total Approved Burden of the ICR in the current inventory: (ROCIS populates)

You must ensure that each of the following is the same as the currently approved burden. If any of the three are not the same, you must complete Part IIIa for every IC in the ICR.

• The total annual number of responses for the ICR (i.e., the sum of every line 1 for each IC in the ICR).

• The total burden hours for the ICR (i.e., the sum of every line 2d for each IC in the ICR); and

• The total cost burden for the ICR (i.e., the sum of every line 2h for each IC in the ICR).

4.

ROCIS will complete this table in Part II, Question 11 from this input. ROCIS will also complete Part III for future reference.

		Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Violation of the PRA	Approved (In current inventory)
a.	Annual Number of Responses for this IC	0 (Line 1)	     	     	     	     	     
b.	Annual IC Time Burden	 0.00 hours (Line 2d x Line 1)	      hours	      hours	      hours	      hours	      hours
c.	Annual IC Cost Burden	$  0.00 (Line 2h x Line 1)	$      	$      	$      	$      	$      

If this ICR is an extension and you are requesting no change in total burden, you may use this worksheet instead of Part IIIa for every information collection in the ICR. Use this sheet gather information about burden for each Information Collection in the ICR. ROCIS will use the information on this sheet to calculate total burden for the IC and the ICR.

1.

Annual Number of Responses:

     

responses per year

2.

Type of Collection: Indicate how much of the burden of this IC is due to reporting, due to record keeping, or due to third-party disclosures. The sum of these three must equal the annual burden of the IC.

Time Per Response

Cost per Response

Frequency of Reporting:

Reporting

a.

     

Hours

e.

$

     

Biennially Decade Monthly Once Semi-annually Annually

Daily Hourly On Occasion Quarterly Weekly

Record keeping

b.

     

Hours

f.

$

     

Third party disclosure

c.

     

Hours

g.

$

     

Total

d.

 0.00

Hours

h.

$

 0.00

3.

Total Approved Burden of the ICR in the current inventory: (ROCIS populates)

You must ensure that each of the following is the same as the currently approved burden. If any of the three are not the same, you must complete Part IIIa for every IC in the ICR.

• The total annual number of responses for the ICR (i.e., the sum of every line 1 for each IC in the ICR).

• The total burden hours for the ICR (i.e., the sum of every line 2d for each IC in the ICR); and

• The total cost burden for the ICR (i.e., the sum of every line 2h for each IC in the ICR).

4.

ROCIS will complete this table in Part II, Question 11 from this input. ROCIS will also complete Part III for future reference.

		Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Violation of the PRA	Approved (In current inventory)
a.	Annual Number of Responses for this IC	0 (Line 1)	     	     	     	     	     
b.	Annual IC Time Burden	 0.00 hours (Line 2d x Line 1)	      hours	      hours	      hours	      hours	      hours
c.	Annual IC Cost Burden	$  0.00 (Line 2h x Line 1)	$      	$      	$      	$      	$      

If this ICR is an extension and you are requesting no change in total burden, you may use this worksheet instead of Part IIIa for every information collection in the ICR. Use this sheet gather information about burden for each Information Collection in the ICR. ROCIS will use the information on this sheet to calculate total burden for the IC and the ICR.

1.

Annual Number of Responses:

     

responses per year

2.

Type of Collection: Indicate how much of the burden of this IC is due to reporting, due to record keeping, or due to third-party disclosures. The sum of these three must equal the annual burden of the IC.

Time Per Response

Cost per Response

Frequency of Reporting:

Reporting

a.

     

Hours

e.

$

     

Biennially Decade Monthly Once Semi-annually Annually

Daily Hourly On Occasion Quarterly Weekly

Record keeping

b.

     

Hours

f.

$

     

Third party disclosure

c.

     

Hours

g.

$

     

Total

d.

 0.00

Hours

h.

$

 0.00

3.

Total Approved Burden of the ICR in the current inventory: (ROCIS populates)

You must ensure that each of the following is the same as the currently approved burden. If any of the three are not the same, you must complete Part IIIa for every IC in the ICR.

• The total annual number of responses for the ICR (i.e., the sum of every line 1 for each IC in the ICR).

• The total burden hours for the ICR (i.e., the sum of every line 2d for each IC in the ICR); and

• The total cost burden for the ICR (i.e., the sum of every line 2h for each IC in the ICR).

4.

ROCIS will complete this table in Part II, Question 11 from this input. ROCIS will also complete Part III for future reference.

		Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Violation of the PRA	Approved (In current inventory)
a.	Annual Number of Responses for this IC	0 (Line 1)	     	     	     	     	     
b.	Annual IC Time Burden	 0.00 hours (Line 2d x Line 1)	      hours	      hours	      hours	      hours	      hours
c.	Annual IC Cost Burden	$  0.00 (Line 2h x Line 1)	$      	$      	$      	$      	$      

Complete this checklist prior to submitting the information collection package to the Clearance Officer. The Clearance Officer will use the information contained in this checklist, along with other information, to certify the information collection prior to submission to OMB. The supporting statement:
	Identifies the statute or regulation authorizing the collection of the information
	Describes efforts taken to avoid the collection of similar information already available, or collected under a different information collection
	Describes, if applicable, methods to minimize the burden on small businesses or other small entities
	Is written using plain English, and all terminology used is unambiguous and understandable to those required to respond to the collection
	Indicates how long records specified in the collection are to be maintained by persons required to maintain the records
	Has dedicated resources to ensure the proper use and processing of the information being collected to enhance (as appropriate) the value of the information to agencies and the public.
	Indicates the use of a statistical survey method (if applicable) that produces valid and reliable results while minimizing undue burden.
	Describes the intended use of information technology to reduce burden and where possible avoid unnecessary system and technology costs.