Information Collection

Department of State Mentor-Protege Program Application

IC 38774 under ICR 201405-1405-001 · OMB 1405-0161.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-4053 Department of State Mentor-Protege Program Application	Form
DS-4053 Department of State Mentor Protégé Program Application Collection Instrument-DS-4053 (7-2014).pdf	Form

IC Title:

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	DS-4053	Department of State Mentor ProtÃ©gÃ© Program Application	Collection Instrument-DS-4053 (7-2014).pdf		Yes	Yes	Fillable Fileable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20	6	14
Annual IC Time Burden (Hours)	240	-54	294
Annual IC Cost Burden (Dollars)	40	40	0

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.