Legacy Treasury Direct Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FS Form 5236 Claim for Proceeds of a Check	Form and Instruction	Modified	Available
Form FS Form 5235 Report of Non-Receipt, Loss, Theft, or Destruction of a Fiscal Agency Check and Application for Replacement	Form and Instruction	Modified	Available
Form FS Form 5191 Application for Recognition as a Natural Guardian of a Minor	Form and Instruction	Modified	Available
Form FS Form 5188 Durable Power of Attorney for Securities and Savings Bonds Transactions	Form and Instruction	Modified	Available
Form FS Form 5179 Security Transfer Request	Form and Instruction	Modified	Available
Form FS Form 5178 Transaction Request	Form and Instruction	Modified	Available
1530-0042_STM.doc	Supporting Statement A	Uploaded 2017-06-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
16570	Treasury Direct Forms	Form and Instruction	Modified	Claim for Proceeds of a Check
16570	Treasury Direct Forms	Form and Instruction	Modified	Report of Non-Receipt, Loss, Theft, or Destruction of a Fiscal Agency Check and Application for Replacement
16570	Treasury Direct Forms	Form and Instruction	Modified	Application for Recognition as a Natural Guardian of a Minor
16570	Treasury Direct Forms	Form and Instruction	Modified	Durable Power of Attorney for Securities and Savings Bonds Transactions
16570	Treasury Direct Forms	Form and Instruction	Modified	Security Transfer Request
16570	Treasury Direct Forms	Form and Instruction	Modified	Transaction Request

ICR Details

OMB Control No: 1530-0042	ICR Reference No: 201706-1530-001
Status: Historical Active	Previous ICR Reference No: 201409-1530-006
Agency/Subagency: TREAS/FISCAL	Agency Tracking No:
Title: Legacy Treasury Direct Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/16/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/30/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2020	36 Months From Approved	10/31/2017
Responses	20,900	0	20,900
Time Burden (Hours)	4,528	0	4,528
Cost Burden (Dollars)	0	0	0

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Abstract: Used to purchase and maintain Treasury Bills, Notes and Bonds.

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Authorizing Statute(s): US Code: 31 USC Chapter 31
  

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 17330	04/10/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 30003	06/30/2017
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Treasury Direct Forms	FS Form 5236, FS Form 5178, FS Form 5179, FS Form 5188, FS Form 5191, FS Form 5235	Transaction Request ,   Security Transfer Request ,   Durable Power of Attorney for Securities and Savings Bonds Transactions ,   Application for Recognition as a Natural Guardian of a Minor ,   Report of Non-Receipt, Loss, Theft, or Destruction of a Fiscal Agency Check and Application for Replacement ,   Claim for Proceeds of a Check

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ICR Summary of Burden

table that charts list 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	20,900	20,900	0	0	0	0
Annual Time Burden (Hours)	4,528	4,528	0	0	0	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:

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Annual Cost to Federal Government: $32,268

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 06/30/2017

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