Information Collection

Experience Rating Report

IC 13005 under ICR 201506-1205-004 · OMB 1205-0164.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0164 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form ETA 204 Experience Rating Report	Form and Instruction
ETA 204 Experience Rating Report ETA 204data map and instructions.docx	Form and Instruction

IC Title:

Experience Rating Report

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	ETA 204	Experience Rating Report	ETA 204data map and instructions.docx		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 53

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	Previously Approved
Annual Number of Responses for this IC	53	53
Annual IC Time Burden (Hours)	27	27
Annual IC Cost Burden (Dollars)	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.