EFT Waiver Form

Request for Payment of Federal Benefit by Check, EFT Waiver Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1510-0077 can be found here:

Documents and Forms

Document Name Document Type
Form 1201W EFT Waiver Form Form and Instruction
1201W Request for Payment of Federal Benefits by Check FMS_Form_1201W_JUN2013.pdf Form and Instruction
FMS 1201W (SP) Solicitud Para Recibir Su Pago de Beneficios Federales E FMS 1201-W (SP) JUN2013.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	EFT Waiver Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 31 CFR Part 208 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1201W	Request for Payment of Federal Benefits by Check	FMS_Form_1201W_JUN2013.pdf		Yes	No	Fillable Printable
Form and Instruction	FMS 1201W (SP)	Solicitud Para Recibir Su Pago de Beneficios Federales En Cheque	FMS 1201-W (SP) JUN2013.pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records
Title: Direct Deposit Enrollment Records-Treasury/FMS .006	FR Citation: 76 FR 42765

Number of Respondents: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	1,380	1,380

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.