Information Collection

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

IC 197205 under ICR 201104-1670-003 · OMB 1670-0023.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.