VCF Claim Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1105-0092 can be found here:

Documents and Forms

Document Name Document Type
Form OMB Number 1105-00 VCF Claim Form Form
OMB Number 1105-00 VCF Claim Form 1105-0092 Claim Form_Final_041416.doc Form
1105-0092_Claim Form_Signature Page_041316.docx Signature page IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	VCF Claim Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	OMB Number 1105-0092	VCF Claim Form	1105-0092 Claim Form_Final_041416.doc		Yes	Yes	Fillable Fileable

Line of Business: Law Enforcement

Subfunction: Citizen Protection

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,164	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10,164	10,164
Annual IC Time Burden (Hours)	3,049	3,049
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Signature page	1105-0092_Claim Form_Signature Page_041316.docx	04/14/2016

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