Information Collection

Certification of Compliance with the Statutory Eligibility Requirements of the Violence Against Women Act as Amended

IC 12639 under ICR 201902-1122-003 · OMB 1122-0001.

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Information Collection (IC) Details

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IC Title:	Certification of Compliance with the Statutory Eligibility Requirements of the Violence Against Women Act as Amended	Agency IC Tracking Number:	1122-0001

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 28 CFR 90

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Law Enforcement

Subfunction: Citizen Protection

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	56	56
Annual IC Cost Burden (Dollars)	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.