Information Collection

VCF Claim Form

IC 221062 under ICR 201906-1105-001 · OMB 1105-0092.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1105-0092 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1105-0092 VCF Claim Form	Form
1105-0092 Victim Compensation Fund Claim Form September 11th Victim Compensation Fund_1105-0092.pdf	Form
1105-0092_Claim Form_Signature Page_041316.docx Signature page	IC Document

IC Title:

VCF Claim Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1105-0092	Victim Compensation Fund Claim Form	September 11th Victim Compensation Fund_1105-0092.pdf		Yes	Yes	Fillable Fileable

Line of Business: Law Enforcement

Subfunction: Citizen Protection

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,164

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	10,164	10,164
Annual IC Time Burden (Hours)	3,049	3,049
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Signature page	1105-0092_Claim Form_Signature Page_041316.docx	04/14/2016

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