Information Collection

DI-4016, Request for Individual Access to Records Protected under the Privacy Act,

IC 256546 under ICR 202504-1093-001 · OMB 1093-0013.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DI-4016 REQUEST FOR INDIVIDUAL ACCESS TO RECORDS PROTECTED UNDER THE PRIVACY ACT DI-4016, Request for Individual Access to Records Protected under the Privacy Act,	Form and Instruction
DI-4016 REQUEST FOR INDIVIDUAL ACCESS TO RECORDS PROTECTED UNDER DI-4016 Request for Individual Access to Records Protected under the Privacy Act_508 and Fillable_FINAL (2).pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	DI-4016				Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records

Title: FWS 5 - National Wildlife Refuge Special Use Permits-Interior

FR Citation: 73 FR 31877

Number of Respondents: 135

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	135	135
Annual IC Time Burden (Hours)	34	34
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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