30-day Notice in IC17-3, attached form

OMB No. 1902-0197 (Expires nn/nn/nnnn)

CEII REQUEST FORM Submit form to CEII Coordinator: 888 First Street, NE Washington, DC 20426 Or via facsimile at 202-208-2106
REQUESTER’S INFORMATION	EMPLOYER/CLIENT INFORMATION
Requester’s name & title:	Name of entity on whose behalf request is filed:
Any other names, e.g., maiden name, used by requester and dates used:	Address of entity listed above:
Requester’s address:	Phone number of entity listed above:
Requester’s phone number:
Business Reference(s)
Name:		Phone #:
Name:		Phone #:
Description of information requested:
Statement of need pursuant to 18 C.F.R.§ 388.113(g)(5)(i)(b), please include: The extent to which a particular function is dependent upon access to the information. Why the function cannot be achieved or performed without access to the information; an explanation of whether other information is available to the requester that could facilitate the same objective. How long the information will be needed. Whether or not the information is needed to participate in a specific proceeding (with that proceeding identified). Explanation of whether the information is needed expeditiously.
Are you willing to sign and abide by an appropriate agreement limiting your use and disclosure of the information requested? Yes □ No □
Are you willing to pay all applicable fees? Yes □ No □ Request a waiver or reduction of fees? Yes □ No □ Fee I agree to pay $ ______________ Notify me if the amount exceeds the entered amount? Yes □ No □
18 U.S.C. § 1001 makes it a crime for any person knowingly and willingly to make to any Agency or Department of the United States any false, fictitious or fraudulent statements as to any matter within its jurisdiction. I hereby attest to the accuracy of the information provided in this CEII request form.
Signature:			Date:

Where to Send Comments on Public Reporting Burden.

The public reporting burden is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding these burden estimates or any aspect of these information collections, including suggestions for reducing this burden, to [email protected], or to the Federal Energy Regulatory Commission, 888 First Street, NE, Washington DC 20426 (Attention: CIO Information Clearance Officer). Comments should also be sent to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503 (Attention: Desk Officer for the Federal Energy Regulatory Commission) at [email protected]. No person shall be subject to any penalty if any collection of information does not display a valid control number (44 U.S.C. § 3512 (a)).