OMB Form 83-I, Paperwork Reduction Act Submission

PAP RWORK REDUCTIO

ACT SUBM ISSIO
OUT

i.

1.

tli . of. vajo md II 'pi lnd ran Rc k ',u um
::!Ol I . s l Bir h Ave.• . \111..: I I. Fla '. I f . \I , /tOOl
3.
b

cv - APPROVAl

E ERGE

1l Y APP OVED COlLEC T

rx TE

e

SIO

or A CURR

le

Tl Y APPROVED COLI EC II

r. or A PREVl USIY
REI ST Arr E T. WITHOU T CtiA
APPROVED CO H ClI
FOR WHIC H APPROVAl HAS EXPIRED

d

REQUESTED BY'

D LEGAT£D

5. SMA U
TITl S
win this information col tion ha Y II
If11p c t on
ub t ntilll nu m

onom

REINS TAl£
N T, WITH CHA
E.O A PREVIOU \ Y
APPRO VED CO HC lIO FO W HlClI APPROVA L li AS EXPIR D
CO UCT

I

U E WITHOUT A

OMB CO TRO

Application for Reloc Ilion Hcncfits
8 . AGENCY FORM NUMB ER(SJ ("
~I~I

.'ppl .••IM-)

1110.9 :II1U ~ I~I 11111.10

9 . KEYWO RDS
I

"A

10 . ABSTRACT

The Olli e..: of • vajo und 1I0pi Indian Relocation 10 1'111 1{ I usc. the information .ollcctcd from 'a\ ajo and 1I0pi mdividuals
and hou : ch ulds \\ ho ha ve prepa red and sub mi ued co mpleted applica tio ns for re loca tion benefit: 10 determi ne their d igihilil)' 10
recei ve such benefits under the 'avajo-l lopi Settlement Ac: o f 19 4 , :lS amended.
12 .

"

d . FARMS

x

c . FEDERAL GOVER M NT

13.

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a.

14 .

t

e.

TOTAL A

d

CU RRE T
fERE C

I.

'~COlIecTed

of t

e

UAl HOURS R QUE TED

EXPLA AlIO
DIFFERE CEo

TOTAL A

UAl CO TS (0 MI

TOTAL A

UAlIZED COST REOUESTED

CURRE T

B INVENTO Y

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TS

DIFfE RE CE

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OF

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rxPlA

B INVENTORY

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AlIO

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OF DFfER£ CE'

(1 1 ProgrlltTl e

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(21 ~trncnt ( •

)

16 . FR

15 .

(In l fWJI6J nth of

TO TAl CAPlT AUST ARTUP COS T

b.
(11 Pete

EFITS

au

CY OF RECORDKEEPI G OR REPORTING o

MI '

RECORD [[PI G O b . THIRD PAR TY OlSC lO UR

X

e . APP lICA TI

FOR

or

HITS

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C.

X

e

REPOR TI G:
( 1I On Occa UXl

b . PROGRAM £VALUAlIO
GE ERAl PURPOSE STAllST

S

0

(410uMt ty

By

(

(7)

d . AUDIT

1 7. STATISTICA L METHOD S
Doe s thl inform ation co c tion mp o y
u ti I me thod ?

x
OMB FORM 83·1 , 10 /95

o

D

(31

nc -timc )

R (frrUdro

I ;1\\ relict: A. Ruzow, Attorney. 0 , IIIR

, JI .1 CO(j,')

hIy

(61 AnnuaIy

OMB CONTROL NUMBER

TITLE

Application for Relocation Benefits
19. CERTIFICATION FOR PAPERWORK REDUCTION ACT SUBMISSIONS
a. PROGRAM OFFICIAL CERTIFICATION
(1)

Signature

/V/;J

(2) Date

On behalf of th is Federal agency, I certify that the collection of information encompassed by this request
complies with 5 eFR 1320.9.
NOTE: The text of 5 eFR 1320.9 , and the related provisions of 5 eFR 1320.8(b)(3) , appear at the end of the
instructions . The certification is to be made w ith reference to those regulatory provisions as set forth in the
instructions.
The following is a summary of the topics, regarding the proposed collection of information, t hat 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 requ irements;

(g) It informs respondents of the information called for under 5 eFR 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 (see note in Item 19 of the instructions) ;
(i) If applicable, it uses effective and efficient statistical survey methodology; and

G> It makes appropriate use of infor mat ion technology .
If you are unab le to certify compliance with any of these provisions, identify the item below and explain the
reason in Item 18 of the Supporting Statement.

b. SENIOR OFFICIAL OR DESIGNEE CERTIFICATION
(2)

ore

/

I / /}!;; / J O/O
OMB FORM 83 -1 (BACK), 10/95

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