Survey Questionnaire

Forms and Documents

Document Name	Status
Form 12844 Survey Questionnaire Form	Modified
Expiration Explanation.rtf Supplementary Document	2008-08-20
Supporting Statement 12884.doc Supporting Statement A	2008-08-20

IC Document Collections

IC ID	Document Title	Status
19625	Survey Questionnaire Form	Modified

ICR Details

OMB Control No: 1545-1922	ICR Reference No: 200808-1545-021
Status: Historical Inactive	Previous ICR Reference No: 200506-1545-037
Agency/Subagency: TREAS/IRS	Agency Tracking No: ah-1922-021
Title: Survey Questionnaire
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 01/15/2009
	Date Received in OIRA: 08/29/2008
Terms of Clearance: Information collection request is withdrawn so that it may be revised to conform to OMB guidelines on the collection of data on race and ethnicity. The request should be resubmitted prior to the expiration of OMB's approval.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2008	36 Months From Approved	01/31/2009
Responses	33,085	0	33,085
Time Burden (Hours)	2,757	0	2,757
Cost Burden (Dollars)	0	0	0

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Abstract: Form 12884 is used to collect statistical information regarding advertising sources and RNO data.

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Authorizing Statute(s): US Code: 26 USC 6103 Name of Law: Confidentiality and disclosure of returns and return information.
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 32082	06/05/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 50667	08/27/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Survey Questionnaire	12844	Survey Questionnaire

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Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $2,950

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/29/2008

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