Application for Data License

License for the Use of Personally Identifiable Information Protected Under the E-Government Act of 2002, Title V and the Privacy Act of 1974

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0297 can be found here:

Documents and Forms

Document Name Document Type
License for the Use of Personally Identifiable Information License Affidavit 2016.docx Other-Affidavit of Nondisclosure
PDR-License-Agreement (2016).docx Other-PDR License Aggreement
Data License Application 2018 Data_License_Application No MTO 2018.docx Form
Data_File_Destruction_Form (2016).docx Data File Destruction IC Document

Information Collection (IC) Details

IC Title:	Application for Data License	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Affidavit of Nondisclosure			License for the Use of Personally Identifiable Information License Affidavit 2016.docx	Yes	Yes	Fillable Fileable
Other-PDR License Aggreement			PDR-License-Agreement (2016).docx	Yes	Yes	Fillable Fileable
Form	N/A	Data License Application 2018	Data_License_Application No MTO 2018.docx	Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Records & Statistical Mgt

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	12	12
Annual IC Cost Burden (Dollars)	600	600

Documents for IC

Title	Document	Date Uploaded
Data File Destruction	Data_File_Destruction_Form (2016).docx	09/30/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.