Information Collection

Annual Certification Report and Equitable Sharing Agreement

IC 182734 under ICR 201409-1123-001 · OMB 1123-0011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1123-0011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OMB Number 1123-00 Annual Certification Report and Equitable Sharing Agreement	Form and Instruction
OMB Number 1123-00 Equitable Sharing Agreement and Certification 1123-0011_Form ESAC_3 0 w SnChkBox noSigDt.pdf www.usdoj.gov/criminal/afmls/	Form and Instruction

IC Title:

Annual Certification Report and Equitable Sharing Agreement

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	OMB Number 1123-0011	Equitable Sharing Agreement and Certification	1123-0011_Form ESAC_3 0 w SnChkBox noSigDt.pdf	www.usdoj.gov/criminal/afmls/	Yes	Yes	Fillable Fileable Signable

Line of Business: Law Enforcement

Subfunction: Citizen Protection

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,600

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,600	-1,288	8,888
Annual IC Time Burden (Hours)	3,800	-645	4,445
Annual IC Cost Burden (Dollars)	0	0	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.