Foreign Diplomatic Services Applications (FDSA)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DS-4299 Domestic Worker Pre-Notification (eGov)	Form	Unchanged	Available
Form DS-4299 Notification of Appointment (Diplomatic) Service Request (eGov)	Form	Unchanged	Repair queued
Form DS-4298 REQUEST BY NON-PIDDED PERSONS FOR NON-ELIGIBILITY LETTER (eGov)	Form	Unchanged	Available
Form DS-4298 REQUEST BY NON-PIDDED PERSONS FOR NON-ELIGIBILITY LETTER	Form	Unchanged	Available
Form DS-4298 REQUEST BY NON-PIDDED PERSONS FOR NON-ELIGIBILITY LETTER	Form	Unchanged	Repair queued
Form DS-1972T Sales Tax Exemption (eGov)	Form	Unchanged	Available
Form DS-1972T Driver License and Tax Exemption	Form and Instruction	Unchanged	Available
Form DS-1972T Driver License and Tax Exemption	Form and Instruction	Unchanged	Repair queued
Form DS-4285 Courtesies of Port (eGov)	Form	Unchanged	Available
Form DS-4285 PORT COURTESIES REQUEST	Form	Unchanged	Available
Form DS-4285 PORT COURTESIES REQUEST	Form	Unchanged	Repair queued
Form DS-4284 White House Tours (eGov)	Form	Unchanged	Available
Form DS-4284 WHITE HOUSE TOURS REQUEST	Form	Unchanged	Available
Form DS-4284 WHITE HOUSE TOURS REQUEST	Form	Unchanged	Repair queued
Form DS-7675 FOREIGN MISSION EMERGENCY AFTER-HOURS CONTACT	Form	Unchanged	Available
Form DS-7675 FOREIGN MISSION EMERGENCY AFTER-HOURS CONTACT	Form	Unchanged	Repair queued
Form DS-4155 VENDOR APPLICATION FOR OFM WEBSITE ACCOUNT	Form and Instruction	Unchanged	Available
Form DS-4155 VENDOR APPLICATION FOR OFM WEBSITE ACCOUNT	Form and Instruction	Unchanged	Repair queued
Form DS-4140 APPLICATION FOR OFM WEBSITE ACCOUNT	Form	Unchanged	Available
Form DS-4140 APPLICATION FOR OFM WEBSITE ACCOUNT	Form	Unchanged	Missing upstream
Form DS-4139 SIGNATURE CARD	Form	Unchanged	Available
Form DS-4139 SIGNATURE CARD	Form	Unchanged	Repair queued
Form DS-4138 Request for Airport Escort Screening Courtesies	Form	Unchanged	Available
Form DS-4138 REQUEST FOR AIRPORT ESCORT SCREENING COURTESIES	Form	Unchanged	Repair queued
Form DS-2008 Notice of Termination (eGov)	Form	Unchanged	Available
Form DS-2008 NOTICE OF TERMINATION OF DIPLOMATIC, CONSULAR, OR FOREIGN GOVERNMENT EMPLOYMENT	Form and Instruction	Unchanged	Available
Form DS-2008 NOTICE OF TERMINATION OF DIPLOMATIC, CONSULAR, OR FOREIGN GOVERNMENT EMPLOYMENT	Form and Instruction	Unchanged	Repair queued
Form DS-2006 Notification of Change Request (eGov)	Form	Unchanged	Available
Form DS-2006 ID Card Renewal - Replacement Request (eGov)	Form	Unchanged	Available
Form DS-2006 NOTIFICATION OF CHANGE IDENTIFICATION CARD REQUEST	Form and Instruction	Unchanged	Available
Form DS-2006 NOTIFICATION OF CHANGE IDENTIFICATION CARD REQUEST	Form and Instruction	Unchanged	Repair queued
Form DS-2005 Notification of Appointment of Honorary Consular Office (eGov)	Form	Unchanged	Available
Form DS-2005 NOTIFICATION OF APPOINTMENT OF HONORARY CONSULAR OFFICER	Form and Instruction	Unchanged	Available
Form DS-2005 NOTIFICATION OF APPOINTMENT OF HONORARY CONSULAR OFFIC	Form and Instruction	Unchanged	Repair queued
Form DS-2004 NOTIFICATION OF APPOINTMENT OF FOREIGN GOVERNMENT EMPLOYEE	Form and Instruction	Unchanged	Available
Form DS-2004 NOTIFICATION OF APPOINTMENT OF FOREIGN GOVERNMENT EMPLOYEE	Form and Instruction	Unchanged	Repair queued
Form DS-2003 Notification of Appointment (Diplomatic) Request (eGov)	Form	Unchanged	Available
Form DS-2003 NOTIFICATION OF APPOINTMENT OF FOREIGN DIPLOMATIC OFFICER AND CAREER CONSULAR OFFICER	Form and Instruction	Unchanged	Available
Form DS-2003 NOTIFICATION OF APPOINTMENT OF FOREIGN DIPLOMATIC OFFICER AND CAREER CONSULAR OFFICER	Form and Instruction	Unchanged	Repair queued
Form DS-1972D Driver License and Non-Driver ID Application (eGov)	Form	Unchanged	Available
Form DS-1972D DRIVER LICENSE APPLICATION	Form	Unchanged	Available
Form DS-1972D DRIVER LICENSE & TAX EXEMPTION APPLICATION	Form	Unchanged	Missing upstream
Form DS-1504 Bonded Warehouse Ordering (eGov)	Form	Unchanged	Available
Form DS-1504 REQUEST FOR CUSTOMS CLEARANCE OF MERCHANDISE	Form and Instruction	Unchanged	Available
Form DS-1504 REQUEST FOR CUSTOMS CLEARANCE OF MERCHANDISE	Form and Instruction	Unchanged	Repair queued
Form DS-104 Replacement Plates (eGov)	Form	Unchanged	Available
Form DS-104 APPLICATION FOR REPLACEMENT PLATES	Form and Instruction	Unchanged	Available
Form DS-104 APPLICATION FOR REPLACEMENT PLATES	Form and Instruction	Unchanged	Repair queued
Form DS-102 Vehicle Title (eGov)	Form	Unchanged	Available
Form DS-102 APPLICATION FOR TITLE	Form and Instruction	Unchanged	Available
Form DS-102 APPLICATION FOR TITLE	Form and Instruction	Unchanged	Repair queued
Form DS-101 Registration (Personal Vehicle)	Form	Unchanged	Available
Form DS-101 APPLICATION FOR REGISTRATION (PERSONAL VEHICLE)	Form and Instruction	Unchanged	Available
Form DS-101 APPLICATION FOR REGISTRATION (PERSONAL VEHICLE)	Form and Instruction	Unchanged	Repair queued
Form DS-100 Registration (Mission Vehicle) Request	Form	Unchanged	Available
Form DS-100 APPLICATION FOR REGISTRATION (MISSION VEHICLE)	Form and Instruction	Unchanged	Available
Form DS-100 APPLICATION FOR REGISTRATION (MISSION VEHICLE) INSTRUCTIONS	Form and Instruction	Unchanged	Missing upstream
Form DS-99 Gasoline Tax Exemption Request: eGov	Form	Unchanged	Available
Form DS-99 APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON GASOLINE	Form and Instruction	Unchanged	Available
Form DS-99 APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON GASOLINE	Form and Instruction	Unchanged	Repair queued
Form DS-98 Utility Tax Exemption Request: eGov	Form	Unchanged	Available
Form DS-98 APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON UTILITIES	Form	Unchanged	Available
Form DS-98 APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON UTILITIES	Form	Unchanged	Missing upstream
Legal Authorities.docx	Supplementary Document	Uploaded 2021-04-14	Available
Legal Authorities.docx	Supplementary Document	Uploaded 2021-04-14	Repair queued
Supporting Statement_1405-0181.docx	Supporting Statement A	Uploaded 2021-04-14	Available
Supporting Statement_1405-0181.docx	Supporting Statement A	Uploaded 2021-04-14	Repair queued
Website display.docx	Supplementary Document	Uploaded 2018-05-29	Available
Website display.docx	Supplementary Document	Uploaded 2018-05-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
230804	Notification of Appointment (Diplomatic) Service Request (eGov)	Form	Unchanged	Domestic Worker Pre-Notification (eGov)
230804	Notification of Appointment (Diplomatic) Service Request (eGov)	Form	Unchanged
230804	Notification of Appointment (Diplomatic) Service Request (eGov)	Instruction	Unchanged
230799	REQUEST BY NON-PIDDED PERSONS FOR NON-ELIGIBILITY LETTER	Form	Unchanged	REQUEST BY NON-PIDDED PERSONS FOR NON-ELIGIBILITY LETTER (eGov)
230799	REQUEST BY NON-PIDDED PERSONS FOR NON-ELIGIBILITY LETTER	Form	Unchanged	REQUEST BY NON-PIDDED PERSONS FOR NON-ELIGIBILITY LETTER
230799	REQUEST BY NON-PIDDED PERSONS FOR NON-ELIGIBILITY LETTER	Form	Unchanged
230797	Driver License and Tax Exemption	Form	Unchanged	Sales Tax Exemption (eGov)
230797	Driver License and Tax Exemption	Form and Instruction	Unchanged	Driver License and Tax Exemption
230797	Driver License and Tax Exemption	Form and Instruction	Unchanged
214076	PORT COURTESIES REQUEST	Form	Unchanged	Courtesies of Port (eGov)
214076	PORT COURTESIES REQUEST	Form	Unchanged	PORT COURTESIES REQUEST
214076	PORT COURTESIES REQUEST	Form	Unchanged
214071	WHITE HOUSE TOURS REQUEST	Form	Unchanged	White House Tours (eGov)
214071	WHITE HOUSE TOURS REQUEST	Form	Unchanged	WHITE HOUSE TOURS REQUEST
214071	WHITE HOUSE TOURS REQUEST	Form	Unchanged
214070	FOREIGN MISSION EMERGENCY AFTER-HOURS CONTACT	Form	Unchanged	FOREIGN MISSION EMERGENCY AFTER-HOURS CONTACT
214070	FOREIGN MISSION EMERGENCY AFTER-HOURS CONTACT	Form	Unchanged
214069	VENDOR APPLICATION FOR OFM WEBSITE ACCOUNT	Form and Instruction	Unchanged	VENDOR APPLICATION FOR OFM WEBSITE ACCOUNT
214069	VENDOR APPLICATION FOR OFM WEBSITE ACCOUNT	Form and Instruction	Unchanged
214067	APPLICATION FOR OFM WEBSITE ACCOUNT	Form	Unchanged	APPLICATION FOR OFM WEBSITE ACCOUNT
214067	APPLICATION FOR OFM WEBSITE ACCOUNT	Form	Unchanged
214064	SIGNATURE CARD	Form	Unchanged	SIGNATURE CARD
214064	SIGNATURE CARD	Form	Unchanged
214059	REQUEST FOR AIRPORT ESCORT SCREENING COURTESIES	Form	Unchanged	Request for Airport Escort Screening Courtesies
214059	REQUEST FOR AIRPORT ESCORT SCREENING COURTESIES	Form	Unchanged
214054	NOTICE OF TERMINATION OF DIPLOMATIC, CONSULAR, OR FOREIGN GOVERNMENT EMPLOYMENT	Form	Unchanged	Notice of Termination (eGov)
214054	NOTICE OF TERMINATION OF DIPLOMATIC, CONSULAR, OR FOREIGN GOVERNMENT EMPLOYMENT	Form and Instruction	Unchanged	NOTICE OF TERMINATION OF DIPLOMATIC, CONSULAR, OR FOREIGN GOVERNMENT EMPLOYMENT
214054	NOTICE OF TERMINATION OF DIPLOMATIC, CONSULAR, OR FOREIGN GOVERNMENT EMPLOYMENT	Form and Instruction	Unchanged
214049	NOTIFICATION OF CHANGE IDENTIFICATION CARD REQUEST	Form	Unchanged	Notification of Change Request (eGov)
214049	NOTIFICATION OF CHANGE IDENTIFICATION CARD REQUEST	Form	Unchanged	ID Card Renewal - Replacement Request (eGov)
214049	NOTIFICATION OF CHANGE IDENTIFICATION CARD REQUEST	Form and Instruction	Unchanged	NOTIFICATION OF CHANGE IDENTIFICATION CARD REQUEST
214049	NOTIFICATION OF CHANGE IDENTIFICATION CARD REQUEST	Form and Instruction	Unchanged
214047	NOTIFICATION OF APPOINTMENT OF HONORARY CONSULAR OFFIC	Form	Unchanged	Notification of Appointment of Honorary Consular Office (eGov)
214047	NOTIFICATION OF APPOINTMENT OF HONORARY CONSULAR OFFIC	Form and Instruction	Unchanged	NOTIFICATION OF APPOINTMENT OF HONORARY CONSULAR OFFICER
214047	NOTIFICATION OF APPOINTMENT OF HONORARY CONSULAR OFFIC	Form and Instruction	Unchanged
214046	NOTIFICATION OF APPOINTMENT OF FOREIGN GOVERNMENT EMPLOYEE	Form and Instruction	Unchanged	NOTIFICATION OF APPOINTMENT OF FOREIGN GOVERNMENT EMPLOYEE
214046	NOTIFICATION OF APPOINTMENT OF FOREIGN GOVERNMENT EMPLOYEE	Form and Instruction	Unchanged
214045	NOTIFICATION OF APPOINTMENT OF FOREIGN DIPLOMATIC OFFICER AND CAREER CONSULAR OFFICER	Form	Unchanged	Notification of Appointment (Diplomatic) Request (eGov)
214045	NOTIFICATION OF APPOINTMENT OF FOREIGN DIPLOMATIC OFFICER AND CAREER CONSULAR OFFICER	Form and Instruction	Unchanged	NOTIFICATION OF APPOINTMENT OF FOREIGN DIPLOMATIC OFFICER AND CAREER CONSULAR OFFICER
214045	NOTIFICATION OF APPOINTMENT OF FOREIGN DIPLOMATIC OFFICER AND CAREER CONSULAR OFFICER	Form and Instruction	Unchanged
214039	DRIVER LICENSE & TAX EXEMPTION APPLICATION	Form	Unchanged	Driver License and Non-Driver ID Application (eGov)
214039	DRIVER LICENSE & TAX EXEMPTION APPLICATION	Form	Unchanged	DRIVER LICENSE APPLICATION
214039	DRIVER LICENSE & TAX EXEMPTION APPLICATION	Form	Unchanged
214032	REQUEST FOR CUSTOMS CLEARANCE OF MERCHANDISE	Form	Unchanged	Bonded Warehouse Ordering (eGov)
214032	REQUEST FOR CUSTOMS CLEARANCE OF MERCHANDISE	Form and Instruction	Unchanged	REQUEST FOR CUSTOMS CLEARANCE OF MERCHANDISE
214032	REQUEST FOR CUSTOMS CLEARANCE OF MERCHANDISE	Form and Instruction	Unchanged
214030	APPLICATION FOR REPLACEMENT PLATES	Form	Unchanged	Replacement Plates (eGov)
214030	APPLICATION FOR REPLACEMENT PLATES	Form and Instruction	Unchanged	APPLICATION FOR REPLACEMENT PLATES
214030	APPLICATION FOR REPLACEMENT PLATES	Form and Instruction	Unchanged
214028	APPLICATION FOR TITLE	Form	Unchanged	Vehicle Title (eGov)
214028	APPLICATION FOR TITLE	Form and Instruction	Unchanged	APPLICATION FOR TITLE
214028	APPLICATION FOR TITLE	Form and Instruction	Unchanged
214027	APPLICATION FOR REGISTRATION (PERSONAL VEHICLE)	Form	Unchanged	Registration (Personal Vehicle)
214027	APPLICATION FOR REGISTRATION (PERSONAL VEHICLE)	Form and Instruction	Unchanged	APPLICATION FOR REGISTRATION (PERSONAL VEHICLE)
214027	APPLICATION FOR REGISTRATION (PERSONAL VEHICLE)	Form and Instruction	Unchanged
214026	APPLICATION FOR REGISTRATION (MISSION VEHICLE) INSTRUCTIONS	Form	Unchanged	Registration (Mission Vehicle) Request
214026	APPLICATION FOR REGISTRATION (MISSION VEHICLE) INSTRUCTIONS	Form and Instruction	Unchanged	APPLICATION FOR REGISTRATION (MISSION VEHICLE)
214026	APPLICATION FOR REGISTRATION (MISSION VEHICLE) INSTRUCTIONS	Form and Instruction	Unchanged
214025	APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON GASOLINE	Form	Unchanged	Gasoline Tax Exemption Request: eGov
214025	APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON GASOLINE	Form and Instruction	Unchanged	APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON GASOLINE
214025	APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON GASOLINE	Form and Instruction	Unchanged
214024	APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON UTILITIES	Form	Unchanged	Utility Tax Exemption Request: eGov
214024	APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON UTILITIES	Form	Unchanged	APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON UTILITIES
214024	APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON UTILITIES	Form	Unchanged

ICR Details

OMB Control No: 1405-0105	ICR Reference No: 202104-1405-003
Status: Active	Previous ICR Reference No: 201803-1405-007
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Foreign Diplomatic Services Applications (FDSA)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/25/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/21/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2025	36 Months From Approved	10/31/2022
Responses	98,780	0	98,780
Time Burden (Hours)	20,727	0	20,727
Cost Burden (Dollars)	0	0	0

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Abstract: Collection information instruments dealing with information collection from the foreign mission community, to include the electronic data compilation (e-Gov), have been combined under one information collection request, collectively referred to as the "Foreign Diplomatic Services Applications." These information collection instruments provide the Office of Foreign Missions and the Office of the Chief of Protocol with the information necessary to provide and administer an effective and efficient benefits, privileges, and immunities program by which foreign missions and eligible applicants may apply for benefits from the U.S. Department of State, to which they are entitled pursuant to the Foreign Missions Act.

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Authorizing Statute(s): US Code: 22 USC 4301 Name of Law: Foreign Missions Act
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 2719	01/13/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 17264	04/01/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 23

table that charts list of burden

IC Title	Form No.	Form Name
APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON GASOLINE	DS-99, DS-99	APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON GASOLINE ,   Gasoline Tax Exemption Request: eGov
APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON UTILITIES	DS-98, DS-98	APPLICATION FOR DIPLOMATIC EXEMPTION FROM TAXES ON UTILITIES ,   Utility Tax Exemption Request: eGov
APPLICATION FOR OFM WEBSITE ACCOUNT	DS-4140	APPLICATION FOR OFM WEBSITE ACCOUNT
APPLICATION FOR REGISTRATION (MISSION VEHICLE) INSTRUCTIONS	DS-100, DS-100	APPLICATION FOR REGISTRATION (MISSION VEHICLE) ,   Registration (Mission Vehicle) Request
APPLICATION FOR REGISTRATION (PERSONAL VEHICLE)	DS-101, DS-101	APPLICATION FOR REGISTRATION (PERSONAL VEHICLE) ,   Registration (Personal Vehicle)
APPLICATION FOR REPLACEMENT PLATES	DS-104, DS-104	APPLICATION FOR REPLACEMENT PLATES ,   Replacement Plates (eGov)
APPLICATION FOR TITLE	DS-102, DS-102	APPLICATION FOR TITLE ,   Vehicle Title (eGov)
DRIVER LICENSE & TAX EXEMPTION APPLICATION	DS-1972D, DS-1972D	DRIVER LICENSE APPLICATION ,   Driver License and Non-Driver ID Application (eGov)
Driver License and Tax Exemption	DS-1972T, DS-1972T	Driver License and Tax Exemption ,   Sales Tax Exemption (eGov)
FOREIGN MISSION EMERGENCY AFTER-HOURS CONTACT	DS-7675	FOREIGN MISSION EMERGENCY AFTER-HOURS CONTACT
NOTICE OF TERMINATION OF DIPLOMATIC, CONSULAR, OR FOREIGN GOVERNMENT EMPLOYMENT	DS-2008, DS-2008	NOTICE OF TERMINATION OF DIPLOMATIC, CONSULAR, OR FOREIGN GOVERNMENT EMPLOYMENT ,   Notice of Termination (eGov)
NOTIFICATION OF APPOINTMENT OF FOREIGN DIPLOMATIC OFFICER AND CAREER CONSULAR OFFICER	DS-2003, DS-2003	NOTIFICATION OF APPOINTMENT OF FOREIGN DIPLOMATIC OFFICER AND CAREER CONSULAR OFFICER ,   Notification of Appointment (Diplomatic) Request (eGov)
NOTIFICATION OF APPOINTMENT OF FOREIGN GOVERNMENT EMPLOYEE	DS-2004	NOTIFICATION OF APPOINTMENT OF FOREIGN GOVERNMENT EMPLOYEE
NOTIFICATION OF APPOINTMENT OF HONORARY CONSULAR OFFIC	DS-2005, DS-2005	NOTIFICATION OF APPOINTMENT OF HONORARY CONSULAR OFFICER ,   Notification of Appointment of Honorary Consular Office (eGov)
NOTIFICATION OF CHANGE IDENTIFICATION CARD REQUEST	DS-2006, DS-2006, DS-2006	NOTIFICATION OF CHANGE IDENTIFICATION CARD REQUEST ,   ID Card Renewal - Replacement Request (eGov) ,   Notification of Change Request (eGov)
Notification of Appointment (Diplomatic) Service Request (eGov)	DS-4299	Domestic Worker Pre-Notification (eGov)
PORT COURTESIES REQUEST	DS-4285, DS-4285	PORT COURTESIES REQUEST ,   Courtesies of Port (eGov)
REQUEST BY NON-PIDDED PERSONS FOR NON-ELIGIBILITY LETTER	DS-4298, DS-4298	REQUEST BY NON-PIDDED PERSONS FOR NON-ELIGIBILITY LETTER ,   REQUEST BY NON-PIDDED PERSONS FOR NON-ELIGIBILITY LETTER (eGov)
REQUEST FOR AIRPORT ESCORT SCREENING COURTESIES	DS-4138	Request for Airport Escort Screening Courtesies
REQUEST FOR CUSTOMS CLEARANCE OF MERCHANDISE	DS-1504, DS-1504	REQUEST FOR CUSTOMS CLEARANCE OF MERCHANDISE ,   Bonded Warehouse Ordering (eGov)
SIGNATURE CARD	DS-4139	SIGNATURE CARD
VENDOR APPLICATION FOR OFM WEBSITE ACCOUNT	DS-4155	VENDOR APPLICATION FOR OFM WEBSITE ACCOUNT
WHITE HOUSE TOURS REQUEST	DS-4284, DS-4284	WHITE HOUSE TOURS REQUEST ,   White House Tours (eGov)

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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	98,780	98,780	0	0	0	0
Annual Time Burden (Hours)	20,727	20,727	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:

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Annual Cost to Federal Government: $4,892,296

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? No

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Common Form ICR:  No

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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: 04/21/2021

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