Information Collection

Annuity Broker Qualification Declaration Form

IC 11774 under ICR 201212-1105-001 · OMB 1105-0080.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1105-0080 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1105-0080 Annuity Broker Qualification Declaration Form	Form and Instruction
1105-0080 Annuity Broker Qualification Declaration Form Annuity Broker Declaration Form.pdf www.justice.gov/civil/settlement/Annuity_Broker_Declaration.pdf	Form and Instruction

IC Title:

Annuity Broker Qualification Declaration Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1105-0080	Annuity Broker Qualification Declaration Form	Annuity Broker Declaration Form.pdf	http://www.justice.gov/civil/settlement/Annuity_Broker_Declaration.pdf	Yes	No	Printable Only

Line of Business: Litigation and Judicial Activities

Subfunction: Resolution Facilitation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	300	0	300
Annual IC Time Burden (Hours)	300	0	300
Annual IC Cost Burden (Dollars)	138	-14,862	15,000

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.