Information Collection

DI-4017, Consent for Disclosure of Records Protected under the Privacy Act

IC 256548 under ICR 202210-1093-001 · OMB 1093-0013.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1093-0013 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DI-4017 DI-4017, Consent for Disclosure of Records Protected under the Privacy Act	Form
DI-4017 CONSENT FOR DISCLOSURE OF RECORDS PROTECTED UNDER THE PR DI-4017 Consent for Disclosure of Records Protected Under the Privacy Act_508 and Fillable_FINAL.pdf	Form
DI-4017 CONSENT FOR DISCLOSURE OF RECORDS PROTECTED UNDER THE PR DI-4017 Consent for Disclosure of Records Protected Under the Privacy Act_508 and Fillable_FINAL (2).pdf	Form and Instruction

IC Title:

DI-4017, Consent for Disclosure of Records Protected under the Privacy Act

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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	DI-4017	CONSENT FOR DISCLOSURE OF RECORDS PROTECTED UNDER THE PRIVACY ACT	DI-4017 Consent for Disclosure of Records Protected Under the Privacy Act_508 and Fillable_FINAL (2).pdf		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title: FWS-5 - National Wildlife Refuge Special Use Permits-Interior

FR Citation: 73 FR 31877

Number of Respondents: 1,190

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,190	1,190
Annual IC Time Burden (Hours)	298	298
Annual IC Cost Burden (Dollars)	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.