Information Collection

Certification of Prison Records by Prison Officials

IC 9742 under ICR 201209-0960-003 · OMB 0960-0688.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0688 can be found here:

Documents and Forms

Document Name Document Type
Certification of Prison Records Template 2012.doc Other-New Certification Template
Model MOU Non Fed 10_10.doc Memorandum of Understanding IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certification of Prison Records by Prison Officials	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 422.107

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-New Certification Template			Certification of Prison Records Template 2012.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,100	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	220,000	20,000	200,000
Annual IC Time Burden (Hours)	11,000	1,000	10,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Memorandum of Understanding	Model MOU Non Fed 10_10.doc	09/25/2012

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