Financial Status Report

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 5655 Financial Status Report	Form	Modified	Available
2900-0165 revised justification.doc	Supporting Statement A	Uploaded 2009-08-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
44123	Financial Status Report	Form	Modified

ICR Details

OMB Control No: 2900-0165	ICR Reference No: 200810-2900-010
Status: Historical Active	Previous ICR Reference No: 200605-2900-010
Agency/Subagency: VA	Agency Tracking No: 2900-0165
Title: Financial Status Report
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/05/2009
	Date Received in OIRA: 06/05/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2012	36 Months From Approved	10/31/2009
Responses	45,553	0	45,553
Time Burden (Hours)	45,553	0	45,553
Cost Burden (Dollars)	0	0	0

---

Abstract: Information reported on this form is necessary to evaluate eligibility for waiver of collection, payment plans or compromises and to determine hardship imposed by an offset schedule as required under 32 USC 3711, 3716 and 5 USC 5514.

---

Authorizing Statute(s): US Code: 38 USC 5314 Name of Law: Indebtedness offsets
   US Code: 31 USC 3711 Name of Law: Collection and compromise
   US Code: 38 USC 3716 Name of Law: Administrative offset
   US Code: 38 USC 3717 Name of Law: Interest and penalty on claims
   US Code: 38 USC 3718 Name of Law: Contracts for collection services
   US Code: 38 USC 5316 Name of Law: Authority to sue to collect certain debts
   US Code: 5 USC 5514 Name of Law: Installment deduction for indebtedness to the United States
   US Code: 38 USC 5302 Name of Law: Waiver of recovery of claims by the United States
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 47	03/12/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 94	05/18/2009
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Financial Status Report	5655	Financial Status Report

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	45,553	45,553	0	0	0	0
Annual Time Burden (Hours)	45,553	45,553	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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:

---

Annual Cost to Federal Government: $66,117

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)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 06/05/2009

---