Form 3170-XXXX TSA Travel Information Form

OMB Control Number: 3170-XXXX
Expiration Date: XX/XX/XXXX

TSA Travel Information Form
Place responses in the column below
Name:
Address:
City/State/Zip
Date of Birth:
Gender (Female or Male):
Middle Initial or Middle Name (as shown on
traveler’s official Government identification)
If traveler is employed by another Federal
agency, please specify name of agency
Routing List Name and/or Approving
Official’s Name (document approval)
Document Preparer
Is this traveler under contract with agency?
Will they be traveling on behalf of your agency
again?
Direct Deposit Form (Required)
Privacy Act Statement
The information that you provide will be used by the Consumer Financial Protection Bureau (CFPB) to make travel
arrangements regarding your appointment as an advisory board member, panel, committee, or other group
membership, or for employment for the United States Government. The information will be used by and disclosed to
employees, contractors, agents and others authorized by the CFPB to receive this information to assist in related
activities. The information may also be disclosed in accordance with the routine uses outlined in the General
Services Administration’s (GSA) published Privacy Act system of records notice, GSA/GOVT-4 – Contracted
Travel Services Program, July 6, 2009 [74 FR 26700].
The collection of this information is authorized by 31 U.S.C. 3511, 3512, and 3523; 5 U.S.C. Chapter 57; and
implementing Federal Travel Regulations (41 CFR Chapters 300-304).
You are not required to submit any identifying information. However, not doing so may prohibit travel arrangements
or reimbursement from being processed.
Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a valid OMB control number. The OMB control number for this
collection is 3170-XXXX. It expires on MM/DD/YYYY. The time required to complete this information collection is estimated
to average approximately 10 minutes per response, including the time for reviewing any instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation
to respond to this collection of information is voluntary. Comments regarding this collection of information, including the
estimated response time, suggestions for improving the usefulness of the information, or suggestions for reducing the burden to
respond to this collection should be submitted to Bureau at the Consumer Financial Protection Bureau (Attention: PRA Office),
1700 G Street NW, Washington, DC 20552, or by email to [email protected].
The Bureau will not disclose any personally identifiable information collected except to the extent that it is required to do so by
law and as provided in the Privacy Act Statement listed above. Additionally, the Bureau will treat the information collected
consistent with its confidentiality regulations at 12 C.F.R. Part 1070, et seq.