State, Local or Tribal Government

Donor Certification Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1090-0009 can be found here:

Documents and Forms

Document Name Document Type
Form DI-3680 State, Local or Tribal Government Form
DI-3680 Donor Certification Form DOI_Donor_Certification_Form_09242015.docx Form

Information Collection (IC) Details

IC Title:	State, Local or Tribal Government	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DI-3680	Donor Certification Form	DOI_Donor_Certification_Form_09242015.docx		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Central Property Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15	-1	16
Annual IC Time Burden (Hours)	5	0	5
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.