Accounts Receivable Forms for Debt Repayment

Forms and Documents

Document	Type	Status	Availability
Form FS Form 123 Financial Statement of Debtor	Form and Instruction	Modified	Available
Form FS Form 122 Request for Recurring Electronic Payments	Form and Instruction	Modified	Available
1530-0075 Supporting Statement Debt Collection Forms 2025.docx	Supporting Statement A	Uploaded 2026-02-25	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
255634	Financial Statement of Debtor	Form and Instruction	Modified	Financial Statement of Debtor
255634	Financial Statement of Debtor	Form and Instruction	Modified
255632	Request for Recurring Electronic Payments	Form and Instruction	Modified	Request for Recurring Electronic Payments
255632	Request for Recurring Electronic Payments	Form and Instruction	Modified

ICR Details

OMB Control No: 1530-0075	ICR Reference No: 202511-1530-001
Status: Received in OIRA	Previous ICR Reference No: 202208-1530-001
Agency/Subagency: TREAS/FISCAL	Agency Tracking No:
Title: Accounts Receivable Forms for Debt Repayment
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/27/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2026
Responses	60	60
Time Burden (Hours)	35	35
Cost Burden (Dollars)	0	1,131

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Abstract: The principal purpose for gathering this information is to evaluate a debtor’s ability to pay their debt and to obtain the debtor’s ACH payment information so recurring electronic payments can be set up to pay their debt.

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Authorizing Statute(s): US Code: 31 USC 321
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 47500	10/01/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 9928	02/27/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Financial Statement of Debtor	FS Form 123	Financial Statement of Debtor
Request for Recurring Electronic Payments	FS Form 122	Request for Recurring Electronic Payments

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	60	60	0	0	0	0
Annual Time Burden (Hours)	35	35	0	0	0	0
Annual Cost Burden (Dollars)	0	1,131	0	0	-1,131	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $2,705

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/27/2026

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