SAFETY Act Block Certification

Support Anti-terrorism by Fostering Effective Technologies Act of 2002

Documents and Forms

Document Name Document Type
Form DHS Form 10004 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

Information Collection (IC) Details

IC Title:	SAFETY Act Block Certification	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DHS Form 10004	SAFETY Act Block Certification	10004_SAFETY_Act_Block_Certification _2_.pdf	www.safetyact.gov	Yes	Yes	Fillable Fileable
Form and Instruction	DHS Form 10004	SAFETY ACT BLOCK CERTIFICATION APPLICATION	10004_SAFETY_Act_Block_Certification _2_.docx	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 %

	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

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.