State, Local or Tribal Governments

Freedom of Information/Privacy Act Request

Documents and Forms

Document Name Document Type
Screenshot - PA Request Form 3.png Other-Privacy Act Request Form Scree
Screenshot - PA Request Form 3.png Other-Privacy Act Request Form Scree
Screenshot - PA Request Form 4.png Other-Privacy Act Request Form Scree
Screenshot - PA Request Form 4.png Other-Privacy Act Request Form Scree

Information Collection (IC) Details

IC Title:	State, Local or Tribal Governments	Agency IC Tracking Number:	OMD

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Privacy Act Request Form Screenshot			Screenshot - PA Request Form 3.png		Yes	Yes	Fillable Fileable Signable
Other-Privacy Act Request Form Screenshot			Screenshot - PA Request Form 4.png		Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records
Title: FCC/OMD-17, Freedom of Information Act (FOIA) and Privacy Act Requests	FR Citation: 81 FR 58930

Number of Respondents: 193	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 92 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	193	193
Annual IC Time Burden (Hours)	16	16
Annual IC Cost Burden (Dollars)	1,281	1,281

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.