Information Collection

Grantee Conflicts of Interest Disclosure Form

IC 249067 under ICR 202108-0417-001 · OMB 0417-0501.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0417-0501 can be found here:

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IC Title:	Grantee Conflicts of Interest Disclosure Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 2 CFR 200.112

Information Collection Instruments:

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

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	230	230

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