83i

PAPERWORK

REDUCTION

ACT SUBM ISSION

Please read the instructions before completing this form, For additional forms or assistance in completing this form, contact your agency's Paperwork
Clearance Officer, Send two copies of this form, the collection instrument to be reviev.ed, the Supporting Statement, and any additional documentation
to Office of Information and Regulatory Affairs, Office of Management and Budget, Docket Library, Room 10102,725 17th Street NW,
WashinQton, DC 20503,
1 Agency/Subagency

originating

2. OM B control

request

D OJ /r:: r;r I L-oJ,o~...,

D'Vl~,'W\

j_ Q_ - ~ Q_

a·i1.

C None
---b,

nu mbe r

t.f"

I

3 Type of infonmatlon
ar

E
E

b

Revision

CI
d

(check

of a currently

Extension,

eC
f

collection

4, Type of review

one)

New collection
without

approved

change,

Reinstatement,

without

which approval
Remstatement.

has expired
with change.

collection

of a currently

change,

of a previously

of a previously

approval has expired
EXisting collection in use without

r::::

collection

collection

C. Emergency

an OMS control

PSI:
form num ber(s)

(check

- Approval

one)
by: __

requested

1_-

for
5. Small entities
Will this information

for which

collection

number

have a significant

a.

collection?

expiration

E Three

economic

- Yes

of small entities?

number

on this information

1
__

C Delegated

substantial

public comments
Yes

8 Agency

approved

b,
c,

collection

approved

!L Regular

6. Requested

3a Public C omm ents
Has the agency received

7 Title

approved

requested

a.

I

impact

on a

No

date

years from approval

b.C

date

Other

Specify: ___

I___

No

I

[UtJo.-_v

L.-~8~

5"~

kfUr~

l6f1.Cfa(Jv..

(if applicable)

t=f)-lboQ
9 Keywords

OV-9"""'b--'h1sl'- ~

--;h.i S tA.JSU~ ._::tits sUV\'u....s ~60-(,I~

10, Abstract

t'«10~.
11, Affected

IndiViduals

c

Not~for~profit

Business

-

13 Annual

~

public (Mark primary

a
b _

with

and recordkeeping

~or~
with

P(l~'1
"X")

oltvv
12, Obligation

0

f

i

~~

veJ.(AIJ ~
'1

/Q,W ~~

to respond

(Mark primary

with

"P" and all others

that apply

with

"X")

i_ Voluntary

a,
b, _
Government

c,

Required

to obtain

reporting

a, Total annualized
b, Total annual

5:00

0
~~

gL

%

and recordkeeping
capital/startup

cost burden

of dollars)

0

costs (O&M)

0

0
Q

of difference

1. Program

0

change

1'1

2 Adjustment

of difference

(in thousands

0

costs

c Total annualized cost requested
d. Current 0 MB inventory
e, Difference
f. Explanation

gz...

or retain benefits

- Mandatory

14. Annual

S"o 0

electronically

'1

•• ","Al,.A:l.J -!IN. ~ "0.'
S,J: N~~I
~}t..-n'-""

w~

o-t..
fhaf apply

~UI'~"b

~~Il«.p~

An:: L...b.-~

hour burden

c Total annual hours requested
d Current OMS Inventory

1 Program

q...._

e,lS:Federal
Govemment
f,_!_ State, Local or Tribal

Institutions

b Total annual responses
1 Percentage
of these responses

e Difference
f Explanation

I

Fanms

d.

of respondents

collected

rnfj

"P" and all of hers

or households

reporting

"-

t40p~en.~

or other for·profit

a Number

t"Gfo~~

fvr-..eH~1

""2-

change

2 Adjustment

15

Purpose
others

of information

that apply

a _Application
b _Program
c _General
Audit
d

collection

(Mark primary

with

"P" and all

for benefits
evaluatIOn
purpose

statistics

e. ~Program

planning

-

Research
f.
g, _Regulatory

Statistical methods
Does thiS Information

or management

or compliance

employ

statisbcal

methods?

~No

or reporting

contact

(check

b _Third

c. '::_Reporting
1. !...._Onoccasion
4. _Quarterly

18, Agency
collection

- Yes

3. _Monthly

2, _Weekly
5. _Semi-annually
8. _Other

(person

all that apply)
party disclosure

6. _Annually

(describe)

who can best answer

questions

regarding

the content

of this

submission)
Name'

Phone:

OMB 83-1

of recordkeeping

rdkeeping

7 _Biennially

-

17

16, Frequency
a. _Reco

with "X")

Robin

Ruth

703-632-7115

02/04

)

OMB CONTROL NUMBER

19. CERTIFICATION

TITLE

FOR PAPERWORK

REDUCTION ACT SUBMISSIONS

a. PROGRAM OFFICIAL CERTIFICATION (Internal 000 Use Only)
(1)

(2) Date

Signature

On behalf of this Federal agency, I certify that the collection of information encompassed
with 5 CFR 1320.9.

by this request complies

NOTE: The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8(b)(3), appear at the end of the
instructions. The certification is to be made with reference to those regulatory provisions as set forth in the
instructions.
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 record keeping 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 (see note in Item 19 of the instructions);
(i) If applicable, it uses effective and efficient statistical survey methodology; and

0) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item below and explain the reason
in Item 18 of the Supporting Statement.

b. SENIOR OFFICIAL OR DESIGNEE CERTIFICATION
(1) Signature

IY\ ~
OMB FORM 83-1(BACK), 10/95

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