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PA PERW ORK REDUCTION A CT SUBM ISSION

Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your agency's Paperwork
Clearance Officer. Send two copies of this form, the collection instrument to be reviewed, the Supporting Statement, and any additional documentation
to: Office of Information and Regulatory Affairs, Office of Management and Budget, Docket Library, Room 10102, 725 17th Street NW,
Washington, DC 20503.
1. Agency/Subagency originating request

2. OM B control nu mbe r

3. Type of information collection (check one)
New collection
a.
Revision of a currently approved collection
b.
c.
Extension, without change, of a currently approved collection
Reinstatement, without change, of a previously approved collection for
d.
which approval has expired
Reinstatement, with change, of a previously approved collection for which
e.
approval has expired
f. ✔
Existing collection in use without an OMB control number

4. Type of review requested (check one)
a.
Regular
05
b. ✔ Em ergency - A pproval reque sted by:
c.
Delegated

3a. Public C omm ents
Has the agency received public comments on this information collection?

6. Requ ested expiration d ate
a. ✔ Three years from approval date

✔

Yes

✔

None

-

a.

FBI/CJIS

b.

/

01

/

2017

5. Small entities
Will this information collection have a significant economic impact on a
✔ No
Yes
substantial number of small entities?

b.

Other Specify:

/

No

7. Title

Address Verification / Change Form
8. Agenc y form num ber(s) (if applicable)

1-797
9. Keywords

Identity History Summary Request Address Change
10. Abstract

DOJ's CJIS is requesting a PRA approval for a new collection utilized by authorized agencies to enroll individuals in the Rap Back Service to ensure
the submitting agency is notified when individuals in positions of trust engage in criminal conduct or individuals under the supervision of a criminal
justice agency commit subsequent criminal acts.

11. Affected public (Mark primary with "P" and all others that apply with "X")
a.
b.
c.

P

d.
e.
f.

Individuals or households
Bus iness or othe r for-pro fit
Not-for-profit institutions

F a rm s
Federal Government
State, Local or T ribal Govern men t

13. Annual reporting and recordkeeping hour burden
720
a. Num ber of respond ents
b. Total annual responses
720
1.Percentage of these responses

collected electronically
50
c. Total annual hours requested 24
0
d. Current O MB inventory
N/A
e. Difference
f. Explanation of difference
1. Program change N/A
2. Adjustment
N/A
15. Purpose of information collection
others that apply with "X")

a.
Application for be nefits
b.
Program evaluation
c.
General purpose statistics
d.
Aud it

%

(M ark prim ary with "P " an d all
e.
f.
g.

P

Program planning or management
Research
Regulatory or compliance

17. Statistical methods
Does this information collection employ statistical methods?
Yes

✔

No

12. Obligation to respond (Mark primary with "P" and all others that apply with "X")
a.
b.
c.

FBI/CJIS
Voluntary
Required to obtain or retain bene fits
Mand atory

14. Annual reporting and recordkeeping cost burden (in thousands of dollars)
a. Total annualized capital/startup costs
N/A
b . T o ta l a nn ua l c os ts (O & M )

14,047.20
c. Total annualized cost requested

N/A
d. Current O MB inventory
0
e. Difference
N/A
f. Explanation of difference
N/A
1. Program change
2. Adjustment
N/A

16. Frequency of recordkeeping or reporting (check all that apply)

a. ✔ Reco rdkeeping
b.
Third party disc losure
c.
Reporting
1.
2.
3.
On occ asion
Wee kly
Mo nthly
4.
Quarterly
5.
Sem i-annually 6.
Ann ually
7.
Biennially
8.
Other (de scribe)
18. Agen cy contact (person who can bes t ans we r qu es tion s reg ard ing the c on ten t of this
submission)
Nam e:

Phone:

Gerry Lynn Brovey, Supervisor

(304) 625-4320

02/04

OMB 83-I

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19. Certification for Paperwork Reduction Act Submissions
On behalf ofthis Federal agency, Icertify thatthe collection ofinformation encompassed bythis request complies with
5 CFR 1320.9.

NOTE: The text of5 CFR 1320.9, and the related provisions of5 CFR 1320.8(b)(3), appear at the endofthe
instructions. The certification is to be made with reference to those regulatory provisions as set forth in
the instructions.

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary forthe proper performance of agency functions;
(b) Ifavoids unnecessary duplication;
(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) Itindicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed byan office that has planned and allocated resourcesfor the efficient and effective manage
ment and use of the information to be collected (see note in Item 19 ofthe instructions);

(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item below and explain the reason in
Item 18 of the Supporting Statement.

Signature of Senior Official or designee

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