Information Collection

Certification of Qualifying State Relief From Disabilities Program

IC 188936 under ICR 202510-1140-005 · OMB 1140-0094.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3210.12 Certification of Qualifying State Relief From Disabilities Program	Form and Instruction
Form 3210.12 Certification of Qualifying State Relief from Disabilities Program Certification of Qualifying State Relief From Disabilities Program	Form and Instruction
3210.12 Certification of Qualifying State Relief from Disabiliti F 3210.12 (2025)_508c_watermark.pdf	Form and Instruction
3210.12 Certification of Qualifying State Relief from Disabiliti F 3210.12 (2025)_508c_watermark.pdf	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: 27 CFR 478.11

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	3210.12				Yes	Yes	Fillable Fileable

Line of Business: Law Enforcement

Subfunction: Crime Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10	0	-40	50
Annual IC Time Burden (Hours)	3	0	-10	13
Annual IC Cost Burden (Dollars)	0	-6	-23	29

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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