Information Collection

Agreement and Undertaking

IC 13662 under ICR 201003-1240-039 · OMB 1240-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0039 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OWCP-1 Agreement and Undertaking	Form and Instruction
OWCP-1 Agreement and Undertaking OWCP-1 DRAFT 9-11-08.pdf www.dol.gov/esa/owcp/dfec/regs/compliance/OWCP-1.pdf	Form and Instruction

IC Title:

Agreement and Undertaking

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 726.110

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-1	Agreement and Undertaking	OWCP-1 DRAFT 9-11-08.pdf	http://www.dol.gov/esa/owcp/dfec/regs/compliance/OWCP-1.pdf	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20	-204	-76	300
Annual IC Time Burden (Hours)	5	-51	-19	75
Annual IC Cost Burden (Dollars)	9	9	0	0

Documents for IC

table that charts IC Documents
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.