Information Collection

203.69 - Application – short form

IC 232630 under ICR 202007-1014-005 · OMB 1014-0005.

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Information Collection (IC) Details

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IC Title:	203.69 - Application â short form	Agency IC Tracking Number:	1014-0005 '21

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 30 CFR 203.69

Information Collection Instruments:

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

Line of Business: Energy

Subfunction: Energy Resource Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1	Number of Respondents for Small Entity: 1

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 60 %

	Requested	Previously Approved
Annual Number of Responses for this IC	1	1
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	100	100

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