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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.