(Electronic Pre-Printed Information), Claim Against the United States for the Proceeds of a Government Check

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FMS 1133 Claim Against the United States for the Proceeds of a Government Check	Form and Instruction	Modified	Available
OMB 1510 0019 Supporting Statement updated.doc	Supporting Statement A	Uploaded 2010-06-17	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
15380	FMS-1133 (Electronic Pre-Printed Information), Claim Against the United States for the Proceeds of a Government Check	Form and Instruction	Modified	Claim Against the United States for the Proceeds of a Government Check

ICR Details

OMB Control No: 1510-0019	ICR Reference No: 201003-1510-005
Status: Historical Active	Previous ICR Reference No: 200703-1510-003
Agency/Subagency: TREAS/FMS	Agency Tracking No:
Title: (Electronic Pre-Printed Information), Claim Against the United States for the Proceeds of a Government Check
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/17/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/17/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2013	36 Months From Approved	08/31/2010
Responses	67,649	0	52,874
Time Burden (Hours)	11,278	0	8,814
Cost Burden (Dollars)	0	0	0

---

Abstract: The FMS-1133 form is used to collect information needed to process an individual's claim for non-receipt of proceeds from a government check. Once the information is analyzed, a determination is made and a recommendation to the program agency to either settle or deny the claim.

---

Authorizing Statute(s): US Code: 31 USC Sec. 321, 3331-3343 Name of Law: Money and Finance; General authority of the Secretary
  

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:
	75 FR 5849	02/04/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 32538	06/08/2010
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
FMS-1133 (Electronic Pre-Printed Information), Claim Against the United States for the Proceeds of a Government Check	FMS 1133	Claim Against the United States for the Proceeds of a Government Check

---

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	67,649	52,874	0	0	14,775	0
Annual Time Burden (Hours)	11,278	8,814	0	0	2,464	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: There was a change in the actual number of respondents and responses from the previous 52,874 to the current 67,649. This increase in respondents added to the Burden Hours needed from 8,814 hours to 11,278 hours for an annual increase of 2,464 hours.

---

Annual Cost to Federal Government: $377,500

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? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

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: 06/17/2010

---