Information Collection

Agreement and Undertaking

IC 13662 under ICR 202401-1240-001 · OMB 1240-0039.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OWCP-1 Agreement and Undertaking	Form
OWCP-1 Agreement and Undertaking OWCP-1 Current form.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form
OWCP-1 Agreement and Undertaking OWCP-1 Changed name.pdf www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 726.110

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	OWCP-1	Agreement and Undertaking	OWCP-1 Changed name.pdf	https://www.dol.gov/agencies/owcp/dcmwc/regs/compliance/blforms#black	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20	3	17
Annual IC Time Burden (Hours)	5	1	4
Annual IC Cost Burden (Dollars)	4	2	2

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.