Application for Data License

License for the Use of Personally Identifiable Information Protected Under the E-Government Act of 2002, Title V and the Privacy Act of 1974

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0297 can be found here:

Documents and Forms

Document Name Document Type
Application for Data License Form
License for the Use of Personally Identifiable Information License Affidavit (2).docx Other-Affidavit of Nondisclosure
PDR License Agreement 9-23-2013.docx Other-PDR License Aggreement
Application for Data License License for the Use of Personally Identifiable Information Application for Data License.docx Form

Information Collection (IC) Details

IC Title:	Application for Data License	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	Application for Data License	License for the Use of Personally Identifiable Information Application for Data License.docx	Yes	Yes	Fillable Fileable
Other-Affidavit of Nondisclosure			License for the Use of Personally Identifiable Information License Affidavit (2).docx	Yes	Yes	Fillable Fileable
Other-PDR License Aggreement			PDR License Agreement 9-23-2013.docx	Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12	0	12
Annual IC Time Burden (Hours)	32	2	30
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.