Information Collection

Public Safety Officers' Disability Beneftis Application

IC 227412 under ICR 202401-1121-004 · OMB 1121-0220.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
disability part A.xlsx	Other-questions
disability part A.xlsx	Other-questions
disability part A with required docs.xlsx	Other-questions
disability part A with required docs.xlsx	Other-questions
disability part B.xlsx	Other-questions
disability part B.xlsx	Other-questions
disability part B with required docs.xlsx	Other-questions
disability part B with required docs.xlsx	Other-questions

IC Title:

Agency IC Tracking Number:

BJA

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-questions	n/a	Yes	Yes	Fillable Fileable
Other-questions	n/a	Yes	Yes	Fillable Fileable
Other-questions	n/a	Yes	Yes	Fillable Fileable
Other-questions	n/a	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	500	500
Annual IC Cost Burden (Dollars)	0	0

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.

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