VCF Claim Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1105-0092 VCF Claim Form	Form	Unchanged	Available
1105-0092 _SS PRA - Revised EC_Form_FINAL_041316_.docx	Supporting Statement A	Uploaded 2019-07-24	Available
Published 30 Day.pdf	Supplementary Document	Uploaded 2019-06-21	Available
VCF Updated Claim Form - Summary of Changes_1105-0092.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2019-06-21	Available
1105-0092_Claim Form_Signature Page_041316.docx	Supplementary Document	Uploaded 2016-04-13	Available
1105-0092_Exhibits_Final Copy_041316.pdf	Supplementary Document	Uploaded 2016-04-13	Available
1105-0092 OMB Form 83-I - REVISED_041316.pdf	Supplementary Document	Uploaded 2016-04-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
221062	VCF Claim Form	Form	Unchanged

ICR Details

OMB Control No: 1105-0092	ICR Reference No: 201907-1105-001
Status: Active	Previous ICR Reference No: 201906-1105-001
Agency/Subagency: DOJ/LA	Agency Tracking No: 1105-0092
Title: VCF Claim Form
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: 09/09/2019
	Date Received in OIRA: 07/24/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2022	36 Months From Approved	09/30/2019
Responses	10,164	0	10,164
Time Burden (Hours)	3,049	0	3,049
Cost Burden (Dollars)	0	0	0

---

Abstract: Under the James Zadroga September 11 Health and Compensation Act of 2010 (P.L. 111-347), the Department of Justice would request biographical information and limited information regarding eligibility for the September 11th Victim Compensation Fund from potential claimants in order to begin the process of determining whether claimants will be eligible for compensation from the Fund.

---

Authorizing Statute(s): PL: Pub.L. 111 - 347 404 Name of Law: James Zadroga 9/11 Health and Compensation Act of 2010
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 347 404 Name of Law: James Zadroga 9/11 Health and Compensation Act of 2010

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 16536	04/19/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 29242	06/21/2019
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
VCF Claim Form	1105-0092	Victim Compensation Fund Claim Form

---

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	10,164	10,164	0	0	0	0
Annual Time Burden (Hours)	3,049	3,049	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:

---

Annual Cost to Federal Government:

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

---

Common Form ICR:  No

---

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: 07/24/2019

---