Affidavit by Individual Surety

Forms and Documents

Document Name	Status
Form FS Form 4094 Affidavit By Individual Surety Form and Instruction	Modified
Supporting Statement_1530-0047.docx Supporting Statement A	2015-11-24

IC Document Collections

IC ID	Document Title	Status
16619	Affidavit By Individual Surety Form and Instruction	Modified

ICR Details

OMB Control No: 1530-0047	ICR Reference No: 201511-1530-009
Status: Historical Active	Previous ICR Reference No: 201409-1530-011
Agency/Subagency: TREAS/FISCAL	Agency Tracking No:
Title: Affidavit by Individual Surety
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/18/2016
	Date Received in OIRA: 11/30/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2019	36 Months From Approved	02/29/2016
Responses	200	0	500
Time Burden (Hours)	183	0	460
Cost Burden (Dollars)	0	0	0

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Abstract: The information is requested to support a request to serve as surety for an indemnification agreement on a Bond of Indemnity.

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Authorizing Statute(s): US Code: 31 USC 31 Name of Law: null
  

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:
	80 FR 58332	09/28/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 74222	11/27/2015
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Affidavit By Individual Surety	FS Form 4094	Affidavit By Individual Surety

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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	200	500	0	-300	0	0
Annual Time Burden (Hours)	183	460	0	-277	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The decrease in respondents is attributed to an examination in use since the last renewal package was submitted. The decrease of 277 hours is an adjustment agency estimate for a total of 183 burden hours requested.

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Annual Cost to Federal Government: $804

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: 11/30/2015

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