Technical Assistance (TA) Request Form for State/Territory/Local Agencies - 9043

Technical Assistance Request and Evaluation (TARE)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1670-0023 can be found here:

Documents and Forms

Document Name Document Type
Form 9043 Technical Assistance (TA) Request Form for State/Territory/Local Agencies - 9043 Form
9043 Technical Assistance (TA) Request Form for State/Territo TA Request - DHS Form 9043 v8 draft.pdf Form
DHS Form 9043_ PRA Statement.doc Privacy Act Statement IC Document

Information Collection (IC) Details

IC Title:	Technical Assistance (TA) Request Form for State/Territory/Local Agencies - 9043	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	9043	Technical Assistance (TA) Request Form for State/Territory/Local Agencies	TA Request - DHS Form 9043 v8 draft.pdf		Yes	Yes	Fillable Printable

Line of Business: Homeland Security

Subfunction: Key Asset and Critical Infrastructure Protection

Privacy Act System of Records
Title: Department of Homeland Security Mailing and Other Lists System of Records	FR Citation: 73 FR 228

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Privacy Act Statement	DHS Form 9043_ PRA Statement.doc	04/08/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.