83i

PAPERWORK REDUCTION ACT SUBMISSION
Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your agency's Paperwork
Clearance Officer. Send two copies of this form, the collection instrument to be reviev.ed, the Supporting Statement, and any additional documentation
to: Office of Information and Regulatory Affairs, Office of Management and Budget, Docket Library, Room 10102, 72517th Street NW,
Washin ton, DC 20503.
1. Agency'Subagency

originating

2. OM B control

request

4. Type

a.

New collection

b.!Q

Revision

cg

of a currently

Extension,

approved

change.

Reinstatement,

without

which

has expired

d.

eO

without

approval

Reinstatement,
approval

I.J:

a. ",
b.r

collection

of a currently

change,

approved

of a previously

collection

approved

c.

collection

Existing

collection

3a. Public C omm ents
Has the agency received

of a previously

approved

collection

an OMB control

comments
Yes

requested

(check

- Approval

:!.....

b.

None

one)

requested

by: __

,__

,__

FDelegated

for

for which

entities

Will this information
substantial

in use without

public

of review
Regular
Emergency

5. Small

with change,

has expired

number

L 1(}_
e-~ .§_ J. _f;

a.

collection

number

of small

have

a significant

entities?

Yes

economic
!_

impact

on a

No

number

on this information

collection?

6. Requested
expiration
date
a. -I Three years from approval

date

b.

Other

Specify:

'

_

.; No

7. Title

8. Agency

form num ber(s)

(if applicable)

9. Keywords

tlt,·)

tll'l

ClJlltCIle?ro.

(rv f2;.fr'I._/
a

public

(Mark

primary

Individuals

or households

b._

Business

or other for-profit

c._

Not-for-profit

13. Annual

e.£

and record keeping

"X")

Govemment
Local or Tribal

Iq./
7111.

/'

P,

to respond

Government

a.
b. _

Required

c. _

Mandatory

14. Annual

C'\ -""

r '--

etA""

(Mark

primary

with

"P" and all others

that apply

with

"X")

to obtain or retain benefits

reporting

and record keeping

a. Total annualized

612

b. Total

t)

annual

capital/startup

costs

c. Total annualized
d. Current

%

7

c. Total annual hours requested'y,
d. Current OMB inventory

/0 i>

'" tit..

r.v

~rh

(a{'-f-tI.f' rJ ,

12. Obligation

6~(1

I(/' b

electronically

with

hour burden

b. Total annual responses
1.Percentage of these responses

(71

OMB

cost burden

(in thousands

of dollars)

costs

(O&M)

cost requested

inventory

e. Difference
f. Explanation
1. Program

(

e. Difference
f. Explanation
1. Program

,

I~

.f_ Voluntary

Federal

f ..!.... State,

of respondents

collected

that apply

Farms

institutions

reporting

a. Number

"P" and all others

,""'--('0 r-'"'

I

L/'lh-rt!~
with

,--

,.---.

7-> d .••.•

r /'Y'PI

-fTa'.Ai/

-To

r~((V~ •.....j.-

11. Affected

f:;

of difference
change

2. Adjustment

of difference
change,

_

2. Adjustment

15. Purpose
others
a.

of information

that apply
Application

b.E:Program
c. _General

collection

(Mark

primary

with

"P" and all

for benefits
evaluation

purpose

statistics

e. ~program
I.

planning

or management

g. _Regulatory

or compliance

employ

statistical
Yes

methods?
..::. No

(check

b. _Third

occasion

2. _Weekly

all that apply)
party disclosure

3. _Monthly

5. _Semi-annually

7. _Biennially

8. !_Other

contact

(person

6. _Annually

(describe)

who can best

answer

questions

regarding

the content

of this

submission)
Name:

Phone:

OMB 83-1

or reporting

4. _Quarterly

18. Agency
collection

of record keeping

c. !_Reporting
1. _On

Research

d. _Audit

17. Statistical
methods
Does this information

16. Frequency

a. _Recordkeeping

with "X")

Kevin R, Furtick

703-632-3222

02/04

19. Certification for Paperwork

Reduction Act Submissions

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR
1320.9.

Note:

The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8(b)(3), appear at the end of the instructions.
The certification is to be made with reference to those regulatory provisions as set forth in the instructions.

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a)

It is necessary for the proper performance of agency functions;

(b)

It avoids unnecessary duplication;

(c)

It reduces burden on small entities;

(d)

It uses plain, coherent, and unambiguous terminology that is understandable to respondents;

(e)

Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f)

It indicates the retention period for recordkeeping requirements;

(g)

It informs respondents of the information called for under 5 CFR 1320.8(b)(3):
(i)

Why the information is being collected;

(ii)

Use of information;

(iii)

Burden estimate;

(iv)

Nature of response (voluntary, required for a benefit, or mandatory);

(v)

Nature and extent of confidentiality; and

(vi)

Need to display currently valid OMB control number;

(h)

It was developed by an office that has planned and allocated resources for the efficient and effective
management and use of the information to be collected (see note in Item 19 of the instructions);

(i)

It uses effective and efficient statistical survey methodology; and

(j)

It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item below and explain the reason in Item 18 of
the Supporting Statement.

Date

;/;tJ /
OMS 83-I

2-tlZO
02/04