VCF Claim Form

Forms and Documents

Document Name	Status
Form OMB Number 1105-00 VCF Claim Form Form	New
Form XXXX Deceased Compensatin Form Form and Instruction	Removed
Form XXXX Deceased Eligibility Form Form and Instruction	Removed
Form XXXX Personal Injury Compensation Form Form and Instruction	Removed
Form XXXX Personal Injury Eligibility Form Form and Instruction	Removed
1105-0092_Claim Form_Signature Page_041316.docx Supplementary Document	2016-04-13
1105-0092_Exhibits_Final Copy_041316.pdf Supplementary Document	2016-04-13
1105-0092 OMB Form 83-I - REVISED_041316.pdf Supplementary Document	2016-04-13
1105-0092 _SS PRA - Revised EC_Form_FINAL_041316_.doc Supporting Statement A	2016-04-13

IC Document Collections

IC ID	Document Title	Status
221062	VCF Claim Form Form	New
202770	Deceased Compensatin Form Form and Instruction	Removed
202769	Deceased Eligibility Form Form and Instruction	Removed
202768	Personal Injury Compensation Form Form and Instruction	Removed
202767	Personal Injury Eligibility Form Form and Instruction	Removed

ICR Details

OMB Control No: 1105-0092	ICR Reference No: 201604-1105-001
Status: Historical Active	Previous ICR Reference No: 201201-1105-003
Agency/Subagency: DOJ/LA	Agency Tracking No:
Title: VCF Claim Form
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/13/2016
	Date Received in OIRA: 04/14/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2019	36 Months From Approved	07/31/2015
Responses	10,164	0	70,000
Time Burden (Hours)	3,049	0	700,000
Cost Burden (Dollars)	0	0	0

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Abstract: Under the James Zadroga September 11 Health and Compensation Act of 2010 (P.L. 111-347), the Department of Justice would request biographical information and limited information regarding eligibility for the September 11th Victim Compensation Fund from potential claimants in order to begin the process of determining whether claimants will be eligible for compensation from the Fund.

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Authorizing Statute(s): PL: Pub.L. 111 - 347 404 Name of Law: James Zadroga 9/11 Health and Compensation Act of 2010
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 347 404 Name of Law: James Zadroga 9/11 Health and Compensation Act of 2010

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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 28707	05/19/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 20674	04/08/2016
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
Deceased Compensatin Form	XXXX	Deceased Compensatin Form
Deceased Eligibility Form	XXXX	Deceased Eligibility Form
VCF Claim Form	OMB Number 1105-0092	VCF Claim Form
Personal Injury Compensation Form	XXXX	Personal Injury Compensatin Form
Personal Injury Eligibility Form	XXXX	Personal Injury Eligibility Form

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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	10,164	70,000	-70,000	10,164	0	0
Annual Time Burden (Hours)	3,049	700,000	-700,000	3,049	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: Reinstatement

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Annual Cost to Federal Government:

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: 04/14/2016

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