Information Collection

Personal Net Worth Form

IC 213920 under ICR 202112-2105-001 · OMB 2105-0510.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Appendix G Personal Net Worth Form	Form and Instruction
Appendix G Personal Net Worth Statement PNW Statement Tech Corrections Final.docx	Form and Instruction
Appendix G Personal Net Worth Statement PNW Statement Tech Corrections Final.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 49 CFR Part 26 (To search for a specific CFR, visit the Code of Federal Regulations.)

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 and Instruction	Appendix G	Personal Net Worth Statement	PNW Statement Tech Corrections Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 9,500

Number of Respondents for Small Entity: 9,500

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	9,500	0	9,500
Annual IC Time Burden (Hours)	95,000	76,000	19,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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