Information Collection

Form 12854, Government Service Information

IC 19619 under ICR 202102-1545-030 · OMB 1545-1919.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 12854 Form 12854, Government Service Information	Form
12854 GOVERNMENT SERVICE INFORMATION f12854--2018-03-00--acc.pdf	Form
12854 GOVERNMENT SERVICE INFORMATION f12854--2018-03-00--acc.pdf	Form
letter.pdf sample Letter	IC Document
letter.pdf sample Letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 26 CFR 315.802 26 CFR 531.202 26 CFR 531.203(c) 26 CFR 315.801

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	12854	GOVERNMENT SERVICE INFORMATION	f12854--2018-03-00--acc.pdf		No		Printable Only

Line of Business: General Government

Subfunction: Taxation Management

Privacy Act System of Records

Title: IRS 36.003, General Personnel and Payroll Records

FR Citation: 80 FR 54063

Number of Respondents: 24,813

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	24,813	24,813
Annual IC Time Burden (Hours)	6,203	6,203
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
sample Letter	letter.pdf	01/17/2018

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