Government, Corporate or Foundation, and Individual Donor Form Application

Forms and Documents

Document Name	Status
Form DS-4271 Government, Corporate or Foundation, and Individual Donor Form Applications Form and Instruction	New
Legal Authorities (10-2014).docx Supplementary Document	2014-12-29
Supporting Statement (10-2014).docx Supporting Statement A	2014-12-29

IC Document Collections

IC ID	Document Title	Status
214454	Government, Corporate or Foundation, and Individual Donor Form Applications Form and Instruction	New

ICR Details

OMB Control No: 1405-0218	ICR Reference No: 201412-1405-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Government, Corporate or Foundation, and Individual Donor Form Application
Type of Information Collection: Existing collection in use without an OMB Control Number	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/29/2014
	Date Received in OIRA: 12/29/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2017	36 Months From Approved
Responses	3,665	0	0
Time Burden (Hours)	305	0	0
Cost Burden (Dollars)	1,833	0	0

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Abstract: The Office of Emergencies in the Diplomatic and Consular Service (EDCS) manages the solicitation and acceptance of gifts to the U.S. Department of State. The information requested via donor letters is a necessary first step to accepting donations. The information is sought pursuant to 22 U.S.C. 2697, 5 U.S.C. 7324 and 22 CFR, Part 3) and will be used by EDCS's Gift Fund Coordinator to demonstrate the donor's intention to donate either an in-kind or monetary gift to the Department. This information is mandatory and must be completed before the gift is received by the Department.

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Authorizing Statute(s): US Code: 5 USC 7342 Name of Law: Foreign Gifts and Decorations Act
   US Code: 22 USC 2697 Name of Law: State Department Basic Authorities Act of 1956
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 38353	07/07/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 63461	10/23/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Government, Corporate or Foundation, and Individual Donor Form Applications	DS-4271, DS-4272, DS-4273	Donor Form - Government ,   Donor Form - Corporate or Foundation ,   Donor Form - Individual

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,665	0	0	0	0	3,665
Annual Time Burden (Hours)	305	0	0	0	0	305
Annual Cost Burden (Dollars)	1,833	0	0	0	0	1,833

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $20,193

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/29/2014

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