Information Collection

SAFETY Act Block Certification

IC 190459 under ICR 202409-1640-002 · OMB 1640-0001.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DHS Form 10004 SAFETY Act Block Certification	Form and Instruction
Form DHS Form 10004 SAFETY Act Block Certification SAFETY Act Block Certification	Form and Instruction
Form DHS Form 10004 SAFETY ACT BLOCK CERTIFICATION APPLICATION SAFETY Act Block Certification	Form and Instruction
DHS Form 10004 SAFETY Act Block Certification 10004_SAFETY_Act_Block_Certification _2_.pdf www.safetyact.gov	Form and Instruction
DHS Form 10004 SAFETY Act Block Certification 10004_SAFETY_Act_Block_Certification _2_.pdf www.safetyact.gov	Form and Instruction
DHS Form 10004 SAFETY ACT BLOCK CERTIFICATION APPLICATION 10004_SAFETY_Act_Block_Certification _2_.docx www.safetyact.gov	Form and Instruction
DHS Form 10004 SAFETY ACT BLOCK CERTIFICATION APPLICATION 10004_SAFETY_Act_Block_Certification _2_.docx www.safetyact.gov	Form and Instruction

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:

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 and Instruction	DHS Form 10004			www.safetyact.gov	Yes	Yes	Fillable Fileable
Form and Instruction	DHS Form 10004			http://www.safetyact.gov	Yes	Yes	Fillable Fileable Signable

Line of Business: Homeland Security

Subfunction: Key Asset and Critical Infrastructure Protection

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	100	100
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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