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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.