Information Collection

USVSST Application

IC 222379 under ICR 202603-1123-001 · OMB 1123-0013.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Notice of Filing C USVSST Notice of Claim USVSST Application	Form and Instruction
Form OMB #1123-0013 USVSST Fund Application Form USVSST Application	Form and Instruction
Form OMB #1123-0013 USVSST Change of Attorney Form USVSST Application	Form and Instruction
Form OMB #1123-0013 USVSST Application's Acknowledgement of Statutory Limitation on Attorneys' Fees USVSST Application	Form and Instruction
Form OMB #1123-0013 UVSST Attorney's Fee Certification USVSST Application	Form and Instruction
Form OMB #1123-0013 USVSST Authorization for Communication USVSST Application	Form and Instruction
Form OMB #1123-0013 USVSST Hearing Request Form USVSST Application	Form and Instruction
Form OMB #1123-0013 USVSST informer Information and Acknowledgement USVSST Application	Form and Instruction
Form OMB #1123-0013 USVSST Direct Deposit Form USVSST Application	Form and Instruction
Form OMB #1123-0013 USVSST Certification of Personal Representative USVSST Application	Form and Instruction
Notice of Filing C USVSST Notice of Claim U.S. Victims of State Sponsored Terrorism Fund Notice of Filing Claim.docx www.usvsst.com	Form and Instruction
OMB #1123-0013 USVSST Fund Application Form 1_USVSST Fund_Application Form_draft.docx	Form and Instruction
OMB #1123-0013 USVSST Change of Attorney Form 2_USVSST Fund_Change of Attorney Form_draft.docx	Form and Instruction
OMB #1123-0013 USVSST Application's Acknowledgement of Statutory Limita 3_USVSST Fund_Applicant's Acknowledgment of Attys' Fees_draft.docx	Form and Instruction
OMB #1123-0013 UVSST Attorney's Fee Certification 4_USVSST Fund_Attorneys' Fee Certification_draft.docx	Form and Instruction
OMB #1123-0013 USVSST Authorization for Communication 5_USVSST Fund_Authorization for Communication_draft.docx	Form and Instruction
OMB #1123-0013 USVSST Hearing Request Form 6_USVSST Fund_Hearing Request Form_draft.docx	Form and Instruction
OMB #1123-0013 USVSST informer Information and Acknowledgement 7_USVSST Fund_Informer Information and Acknowledgment_draft.docx	Form and Instruction
OMB #1123-0013 USVSST Direct Deposit Form 8_USVSST Fund_Direct Deposit - ACH Payment Form_draft.docx	Form and Instruction
OMB #1123-0013 USVSST Certification of Personal Representative 9_USVSST Fund_Certification of Personal Representative_draft.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

USVSST Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 10609

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Notice of Filing Claim	http://www.usvsst.com	Yes	Yes	Fillable Fileable
Form and Instruction	OMB #1123-0013		Yes	Yes	Fillable Fileable
Form and Instruction	OMB #1123-0013		Yes	Yes	Fillable Fileable
Form and Instruction	OMB #1123-0013		Yes	Yes	Fillable Fileable
Form and Instruction	OMB #1123-0013		Yes	Yes	Fillable Fileable
Form and Instruction	OMB #1123-0013		Yes	Yes	Fillable Fileable
Form and Instruction	OMB #1123-0013		Yes	Yes	Fillable Fileable
Form and Instruction	OMB #1123-0013		Yes	Yes	Fillable Fileable
Form and Instruction	OMB #1123-0013		Yes	Yes	Fillable Fileable
Form and Instruction	OMB #1123-0013		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Disaster Management

Subfunction: Disaster Repair and Restore

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 85 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,000	1,300	700
Annual IC Time Burden (Hours)	2,000	1,125	875
Annual IC Cost Burden (Dollars)	0	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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