Information Collection

Statement of Payments Received

IC 129772 under ICR 201507-1545-024 · OMB 1545-0364.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1545-0364 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4669 Statement of Payments Received	Form and Instruction
4669 Statement of Payments Received Form_4669[1].pdf	Form and Instruction

IC Title:

Statement of Payments Received

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	4669	Statement of Payments Received	Form_4669[1].pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 85,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	85,000	13,000	72,000
Annual IC Time Burden (Hours)	21,250	3,250	18,000
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.