Information Collection

VCF Claim Form

IC 221062 under ICR 201604-1105-001 · OMB 1105-0092.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.