Financial Capability Form

Forms and Documents

Document Name	Status
Form 1122-XXXX Financial Capability Form Form	Unchanged
VAWA13.pdf Supplementary Document	2016-06-20
vawa2000.pdf Supplementary Document	2016-06-20
vawa2005.pdf Supplementary Document	2016-06-20
vawa.pdf Supplementary Document	2016-06-20
20 CFR REGS.docx Supplementary Document	2016-06-20
1122-NEW Fin Cap Sup State_062116.doc Supporting Statement A	2016-06-21

IC Document Collections

IC ID	Document Title	Status
222054	Financial Capability Form Form	Unchanged

ICR Details

OMB Control No: 1122-0030	ICR Reference No: 201905-1122-001
Status: Active	Previous ICR Reference No: 201606-1122-001
Agency/Subagency: DOJ/OVW	Agency Tracking No: 1122-0030
Title: Financial Capability Form
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: 12/09/2019
	Date Received in OIRA: 09/30/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2022	36 Months From Approved	12/31/2019
Responses	40	0	40
Time Burden (Hours)	160	0	160
Cost Burden (Dollars)	0	0	0

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Abstract: In accordance with 2 CFR 200.205, the Office on Violence Against Women is seeking information required for assessing the financial risk of an applicant’s ability to administer federal funds. The form includes a mix of check box and narrative questions related to the organization’s financial systems, policies and procedures. The affected public includes non-governmental applicants to OVW grant programs that do not currently (or within the last 3 years) have funding from OVW.

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Authorizing Statute(s): US Code: 42 USC 13925, et seq. Name of Law: Violence Against Women Act
  

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:
	84 FR 22521	05/17/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 35424	07/23/2019
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Financial Capability Form	1122-XXXX	Financial Capability 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	40	40	0	0	0	0
Annual Time Burden (Hours)	160	160	0	0	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: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $2,240

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 09/30/2019

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