Web Intake Form

Pilot Intake Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1505-0236 can be found here:

Documents and Forms

Document Name Document Type
6.9.11 Complaint intake screenshot 1.png Other-Screen Shot
6.9.11 Complaint intake screenshot 1.1.png Other-Screen Shot
6.9.11 Complaint intake screenshot 2.png Other-Screen Shot
6.9.11 Complaint intake screenshot 3.png Other-Screen Shot
6.9.11 Complaint intake screenshot 3.1.png Other-Screen Shot

Information Collection (IC) Details

IC Title:	Web Intake Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screen Shot	6.9.11 Complaint intake screenshot 1.png	Yes	Yes	Fillable Fileable
Other-Screen Shot	6.9.11 Complaint intake screenshot 1.1.png	Yes	Yes	Fillable Fileable
Other-Screen Shot	6.9.11 Complaint intake screenshot 2.png	Yes	Yes	Fillable Fileable
Other-Screen Shot	6.9.11 Complaint intake screenshot 3.png	Yes	Yes	Fillable Fileable
Other-Screen Shot	6.9.11 Complaint intake screenshot 3.1.png	Yes	Yes	Fillable Fileable

Line of Business: Economic Development

Subfunction: Industry Sector Income Stabilization

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56,250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 60 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	56,250	56,250
Annual IC Time Burden (Hours)	6,563	6,563
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.