Information Collection

Certification of Prison Records by Prison Officials

IC 9742 under ICR 201506-0960-010 · OMB 0960-0688.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0688 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Certification of Prison Records Template 2012.doc	Other-New Certification Template
Non Fed OGC approved Model MOU 09 2013.doc Memorandum of Understanding	IC Document

IC Title:

Certification of Prison Records by Prison Officials

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 422.107

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
Other-New Certification Template			Certification of Prison Records Template 2012.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	200,000	-20,000	220,000
Annual IC Time Burden (Hours)	10,000	-1,000	11,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Memorandum of Understanding	Non Fed OGC approved Model MOU 09 2013.doc	07/09/2015

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.