Information Collection

Disclosure Form 4 (17 CFR 240.16a-3(k))

IC 240087 under ICR 202203-7100-002 · OMB 7100-0091.

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Information Collection (IC) Details

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IC Title:	Disclosure Form 4 (17 CFR 240.16a-3(k))	Agency IC Tracking Number:	FR H-1

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 12 CFR 208.36 17 CFR 240.16a-3(k)

Information Collection Instruments:

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

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2	Number of Respondents for Small Entity: 1

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	70	0	70
Annual IC Time Burden (Hours)	35	24	11
Annual IC Cost Burden (Dollars)	0	0	0

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