Privacy and Repayment Agreement

U.S. Repatriation Program Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0474 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Privacy and Repayment Agreement Form and Instruction
1 Privacy and Repayment Agreement Form RR-05 Privacy and Repayment Agreement Form.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Privacy and Repayment Agreement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Privacy and Repayment Agreement Form	RR-05 Privacy and Repayment Agreement Form.doc		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25,000	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	25,000	25,000
Annual IC Time Burden (Hours)	1,250	1,250
Annual IC Cost Burden (Dollars)	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.