Information Collection

Debt Collection Disclosure Forms Focus Groups and User Experience Study (Round 2)

IC 214852 under ICR 201206-3170-002 · OMB 3170-0022.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3170-0022 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Debt Disclosure Privacy Statement_2014-5-14.docx (1).pdf	Other-Privacy Statement
Debt Disclosure_Pre-Session Questionnaire_2014-5-14 (2).pdf	Other-Questionnaire
Debt Disclosure_Screener (1).pdf	Other-Screenr
FINAL Debt Disclosure_Consent Form_2014_5-14-14 (1).pdf	Other-Consent form
G-Notice 1_2014-5-14.docx (1).pdf	Other-sample notice
G-Notice 2_2014-5-14.docx (1).pdf	Other-sample notice
Debt Disclosure User Experience Test Discussion Guide.pdf	Other-Discussion Guide
IC Template_Debt Disclosure revised 2 5 15.docx Submission Template	IC Document

IC Title:

Debt Collection Disclosure Forms Focus Groups and User Experience Study (Round 2)

Agency IC Tracking Number:

10038 (Rev)

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Privacy Statement	Debt Disclosure Privacy Statement_2014-5-14.docx (1).pdf	No		Printable Only
Other-Questionnaire	Debt Disclosure_Pre-Session Questionnaire_2014-5-14 (2).pdf	No		Paper Only
Other-Screenr	Debt Disclosure_Screener (1).pdf	Yes	Yes	Fillable Fileable
Other-Consent form	FINAL Debt Disclosure_Consent Form_2014_5-14-14 (1).pdf	No		Paper Only
Other-sample notice	G-Notice 1_2014-5-14.docx (1).pdf	No		Paper Only
Other-sample notice	G-Notice 2_2014-5-14.docx (1).pdf	No		Paper Only
Other-Discussion Guide	Debt Disclosure User Experience Test Discussion Guide.pdf	No		Paper Only

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records

Title: Consumer Education and Engagement Records

FR Citation: 77 FR 60382

Number of Respondents: 140

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	45	45
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Submission Template	IC Template_Debt Disclosure revised 2 5 15.docx	02/05/2015

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