Regulatory Collection Filing

Eligibility Questionnaire for HAVANA Act Payments

RCF 202601-0503-001CF · Host ICR 202601-1405-001 · OMB 1405-0250

RCF Summary

Request for correction metadata
Host OMB Control No.	1405-0250
Host ICR Reference No.	202601-1405-001
Agency/Subagency	USDA/AgSEC
Status	Active
Type of RCF	RCF Recertification
OIRA Conclusion Action	Approved
Date Received in OIRA	2026-01-07
Conclusion Date	2026-01-07
Related Links	OMB 1405-0250 · ICR 202601-1405-001 · Previous RCF 202306-0503-001CF · Retrieve Notice of Action (NOA)

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Title: Eligibility Questionnaire for HAVANA Act Payments

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Type of RCF: RCF Recertification
OIRA Conclusion Action: Approved	Conclusion Date: 01/07/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/07/2026
Terms of Clearance:

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Description of Agency Usage: The Eligibility Questionnaire will be used to authorize a lump sum payment to the victim of an AHI.

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Authorizing Statute(s): None

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Annual Cost to Federal Government:
Agency Contact: John Decato 202 720-1021

Common Form Information Collections (IC) in this RCF:

table that charts list of ICs
IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.	Form Name
Eligibility Questionnaire For HAVANA Act Payments		10	5	0	Form and Instruction	DS-4316	Eligibility Questionnaire for Havana Act Payments
Eligibility Questionnaire For HAVANA Act Payments		10	5	0	Form	DS-4316	Eligibility Questionnaire for HAVANA Act payments

RCF Summary of Burden:

table that charts list of burden
	Total Approved	Previously Approved
Annual Number of Responses	10	10
Annual Time Burden (Hours)	5	5
Annual Cost Burden (Dollars)	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: