ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS-FBI

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DS-4316 Eligibility Questionnaire for HAVANA Act payments	Form	Modified	Available
Form DS-4316 Eligibility Questionnaire for Havana Act Payments	Form and Instruction	Modified	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
259681	Eligibility Questionnaire For HAVANA Act Payments	Form	Modified	Eligibility Questionnaire for HAVANA Act payments
259681	Eligibility Questionnaire For HAVANA Act Payments	Form and Instruction	Modified	Eligibility Questionnaire for Havana Act Payments

ICR Details

OMB Control No: 1405-0250	ICR Reference No: 202605-1110-001CF
Status: Active	Previous ICR Reference No: 202601-1110-001CF
Agency/Subagency: DOJ/FBI	Agency Tracking No:
Title: ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS-FBI
Type of Information Collection: RCF Recertification	Common Form ICR:
Type of Review Request:
OIRA Conclusion Action: Approved	Conclusion Date: 05/12/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/12/2026
Terms of Clearance: DOJ is authorized to make only minor changes to the host IC to make it usable for DOJ claimants. This includes changing agency seals, updating addresses, etc. Any substantive change that modifies the information being collected in any way falls outside of the common form approval and is prohibited.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2029	36 Months From Approved	05/31/2026
Responses	25	0	25
Time Burden (Hours)	13	0	13
Cost Burden (Dollars)	0	0	0

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Abstract:

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Authorizing Statute(s): PL: Pub.L. 117 - 46 1828 Name of Law: The Havana Act of 2021
  

Citations for New Statutory Requirements: PL: Pub.L. 117 - 46 1828 Name of Law: HAVANA Act of 2021

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR?

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Eligibility Questionnaire For HAVANA Act Payments	DS-4316, DS-4316	Eligibility Questionnaire for Havana Act Payments ,   Eligibility Questionnaire for HAVANA Act payments

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	25	25	0	0	0	0
Annual Time Burden (Hours)	13	13	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

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:

Does this IC contain surveys, censuses, or employ statistical methods?

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.    

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.    

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? No

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Common Form ICR: 

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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:

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