Information Collection

Domestic Abuse Victim Reporting Option Statement

IC 259324 under ICR 202302-0704-008 · OMB 0704-0666.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0666 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD Form 2967 Domestic Abuse Victim Reporting Option Statement	Form and Instruction
DD Form 2967 Domestic Abuse Victim Reporting Option Statement dd2967_20230419.PDF	Form and Instruction
DD Form 2967 Domestic Abuse Victim Reporting Option Statement dd2967_20230419.PDF	Form and Instruction

IC Title:

Domestic Abuse Victim Reporting Option Statement

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	DD Form 2967	Domestic Abuse Victim Reporting Option Statement	dd2967_20230419.PDF		No		Paper Only

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20,000	20,000
Annual IC Time Burden (Hours)	25,000	25,000
Annual IC Cost Burden (Dollars)	708,800	708,800

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.