Form 5 - Annual Statement of Beneficial Ownership

Forms and Documents

Document Name	Status
Form SEC 2270 Form 5 - Annual Statement of Beneficial Ownership Form	Modified
Form 5.SupportingStatement.2017.pdf Supporting Statement A	2017-04-25
January 2016 EDGAR PIA.pdf Supplementary Document	2017-04-25

IC Document Collections

IC ID	Document Title	Status
34921	Form 5 - Annual Statement of Beneficial Ownership Form	Modified

ICR Details

OMB Control No: 3235-0362	ICR Reference No: 201704-3235-008
Status: Historical Active	Previous ICR Reference No: 201312-3235-022
Agency/Subagency: SEC	Agency Tracking No: CF 270-323
Title: Form 5 - Annual Statement of Beneficial Ownership
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/28/2017
	Date Received in OIRA: 04/26/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved	06/30/2017
Responses	5,939	0	4,600
Time Burden (Hours)	5,939	0	4,600
Cost Burden (Dollars)	0	0	0

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Abstract: Form 5 is an annual statement of beneficial ownership used by officers, directors and ten percent shareholders of companies with securities registered under Section 12 of the Securities Exchange Act of 1934.

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Authorizing Statute(s): US Code: 15 USC 78l, 78p Name of Law: Securities Exchange Act of 1934
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 8968	02/01/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 19298	04/26/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Form 5 - Annual Statement of Beneficial Ownership	SEC 2270	Form 5 Annual Statement of Beneficial Ownership

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	5,939	4,600	0	0	1,339	0
Annual Time Burden (Hours)	5,939	4,600	0	0	1,339	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The increase in burden hours of 1,339 is due to an adjustment. The increase in burden hours reflects an increase in the number of respondents filing Form 5 with the Commission.

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Annual Cost to Federal Government: $25,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids 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) It indicates 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 by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(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 by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/26/2017

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