Freedom of Information/Privcy Act Request

Forms and Documents

Document Name	Status
Form G-639 Freedom of Information/Privcy Act Request Form	Modified
G-639 Supp Statement 1.9.12.doc Supporting Statement A	2012-01-09
TOC_G-639 Form and Instructions 08-23-2011.doc Supplementary Document	2011-09-01
I-639 PUBLISHED 30-day notice.pdf Supplementary Document	2011-09-01
G-639 60-Day Notice 5-3-11 PUBLISHED.doc Supplementary Document	2011-09-01
FOIA PIA.pdf Supplementary Document	2011-09-01
SORN.doc Supplementary Document	2010-08-12
Approved PTA G-639.pdf Supplementary Document	2010-08-12
Reference Citations.doc Supplementary Document	2010-08-12

IC Document Collections

IC ID	Document Title	Status
21021	Freedom of Information/Privcy Act Request Form	Modified

ICR Details

OMB Control No: 1615-0102	ICR Reference No: 201109-1615-002
Status: Historical Active	Previous ICR Reference No: 201008-1615-002
Agency/Subagency: DHS/USCIS	Agency Tracking No:
Title: Freedom of Information/Privcy Act Request
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/29/2012
	Date Received in OIRA: 09/15/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	36 Months From Approved	01/31/2012
Responses	100,000	0	100,000
Time Burden (Hours)	25,000	0	25,000
Cost Burden (Dollars)	0	0	0

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Abstract: This form is provided as a convenient means for persons to provide data necessary for identification of a particular record desired under FOIA/PA.

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Authorizing Statute(s): US Code: 5 USC 552 Name of Law: Administrative Procedures Act
  

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:
	76 FR 24908	05/03/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 53929	08/30/2011
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Freedom of Information/Privcy Act Request	G-639	Freedom of Information/Privacy Act Request

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ICR Summary 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	100,000	100,000	0	0	0	0
Annual Time Burden (Hours)	25,000	25,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	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: $4,018,000

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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? Uncollected

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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: 09/15/2011

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