83-i

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 reviewed, the Supporting Statement, and any additional documentation
to: Office of Information and Regulatory Affairs, Office of Management and Budget, Docket Library, Room 10102, 725 17th Street NW,
Washington, DC 20503.
1. Agency/Subagency originating request

2. OMB control number

3. Type of information collection (check one)
b.

✔

New Collection

a. ✔ Regular

Revision of a currently approved collection

b.

Emergency - Approval requested by: ____/____/____

c.

Delegated

5. Small entities

collection for which approval has expired
Reinstatement, with change, of a previously approved

Will this information collection have a significant economic impact on a
substantial number of small entities?

collection for which approval has expired

Yes

Existing collection in use without an OMB control number

f.

__ __ __ __

4. Type of review requested (check one)

c. ✔ Extension of a currently approved collection
Reinstatement, without change, of a previously approved
d.
e.

None

__ __ __ __ - __0070
__ __ __
a. __ 1110

FBI/CJIS
a.

b.

No

✔

6. Requested expiration date

For b-f, note Item A2 of Supporting Statement instructions

a.

✔

Three years from the approval date

b.

_____/_____

7. Title

Credit Card Payment Form
8. Agency form number(s) (if applicable)

1-786
9. Keywords

Departmental Order 556-73, Rap Sheet, Criminal History Request, Credit Card, Payment
10. Abstract
DOJ's CJIS is requesting PRA approval for a revision of a currently approved collection to provide individuals requesting a copy of their Criminal History/Rap
Sheet with an alternative option of payment (credit card) for the $18 fee associated with the record request.

11. Affected public (Mark primary with "P" and all others with "X")

12. Obligation to respond (Mark primary with "P" and all others that apply with "X")
a. P Voluntary

P Individuals or households
a. __

d. __ Farms

b. __ Business or other for-profit

e. __ Federal Government

c. __ Not-for-profit institutions

f. __ State, Local, or Tribal Government

b. P Required to obtain or retain benefits

13. Annual reporting and recordkeeping hour burden
a. Number of respondents
b. Total annual responses

Mandatory
c.
14. Annual reporting and recordkeeping cost burden(in thousands of dollars)
a. Total annualized capital/startup costs

28,309
28,309

b. Total annual costs (O&M)

1. Percentage of these responses

c. Total annualized cost requested

0
c. Total annual hours requested 935
2667
d. Current OMB inventory
1732
e. Difference

%

collected electronically

d. Current OMB inventory
e. Difference
f. Explanation of difference
1. Program change

f. Explanation of difference
1. Program change

N/A
1,458,803.00
1,458,803.00
173,797.00
1,285,006.00

2. Adjustment

N/A
Added staffing

N/A
Automation

2. Adjustment
15. Purpose of information collection (Mark primary with "P" and all others

16. Frequency of recordkeeping or reporting(check all that apply)
a. ✔ Recordkeeping

that apply with "X")
a. __ Application for benefits

e. __ Program planning or management c.

b. __ Program evaluation

f. __ Research

c. __ General purpose statistics g. P
__ Regulatory or compliance
d. __ Audit

b.

Third party disclosure

Reporting:
1.

On occasion

2.

Weekly

4.
7.

Quarterly
Biennially

5.
8.

Semi-annually 6.
Annually
Other (describe) ____________

3.

Monthly

18. Agency contact (person who can best answer questions regarding the content

17. Statistical methods
Does this information collection employ statistical methods?
Yes

No

✔

of this submission)
Larry E. Cotton-Zinn, Management and Program Analyst
Name: ______________________________________________________

(304) 625-5590
Phone: ______________________________________________________
OMB 83-I

10/95

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) If avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(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 (if applicable); 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.

Signature of Senior Official or designee

OMB 83-I

Date

10/95