Information Collection

Authorization Letter for Data Provider

IC 183227 under ICR 201203-1640-003 · OMB 1640-0012.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 10039 (12/07) Authorization Letter Data Provider Authorization Letter for Data Provider	Form and Instruction
10039 (12/07) Authorization Letter Data Provider 10039_PREDICT_AuthorizationLtr_DP_v1.2.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

10039

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

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 and Instruction	10039 (12/07)				Yes	No	Fillable Printable

Line of Business: Homeland Security

Subfunction: Key Asset and Critical Infrastructure Protection

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-2	2
Annual IC Time Burden (Hours)	-2	2
Annual IC Cost Burden (Dollars)	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.

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