83i

PAPERWORK REDUCTION ACT SUBMISSION

Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your agency's Paperwork
Clearance Officer. Send two copies of this form, the collection instrument to be reviewed, the Supporting Statement, and any additional documentation
to: Office of Information and Regulatory Affairs, Office of Management and Budget, Docket Library, Room 10102, 725 17th Street NW,
Washington, DC 20503.
1. Agency/Subagency originating request

b. ✔ None

2. OMB control number
a. __ __ __ __ __ - __ __ __ __

FBI/CJIS
3. Type of information collection (check one)

__ __ __ __

4. Type of review requested (check one)

a.

New Collection

b.

Revision of a currently approved collection

Regular
a.
09 23 16
b. ✔ Emergency - Approval requested by: ____/____/____

c.
d.

Extension of a currently approved collection
Reinstatement, without change, of a previously approved

e.

collection for which approval has expired
Reinstatement, with change, of a previously approved

Delegated

c.

5. Small entities
Will this information collection have a significant economic impact on a
substantial number of small entities?

collection for which approval has expired

Yes

f. ✔ Existing collection in use without an OMB control number

No

✔

6. Requested expiration date

For b-f, note Item A2 of Supporting Statement instructions

a.

✔

Three years from the approval date

b.

_____/_____

7. Title

Credit Card Payment Form
8. Agency form number(s) (if applicable)

1-186
9. Keywords

Departmental Order 556-73, Rap Sheet, Criminal History Request,
10. Abstract
DOJ's CJIS is requesting a PRA approval for an existing collection in use without an OMB control number. The 1-786 is utilized to provide individuals requesting
a copy of their Criminal History/Rap Sheet with an alternate option of payment (credit card) for the $18 fee associate with requesting their record.

11. Affected public (Mark primary with "P" and all others with "X")

12. Obligation to respond (Mark primary with "P" and all others that apply with "X")
a. P Voluntary

P Individuals or households
a. __

d. __ Farms

b. __ Business or other for-profit

e. __ Federal Government

c. __ Not-for-profit institutions

f. __ State, Local, or Tribal Government

13. Annual reporting and recordkeeping hour burden
a. Number of respondents
b. Total annual responses

a. Total annualized capital/startup costs

80,000
80,000

b. Total annual costs (O&M)

1. Percentage of these responses

c. Total annualized cost requested

N/A
c. Total annual hours requested 2,667
0
d. Current OMB inventory
N/A
e. Difference

%

collected electronically

d. Current OMB inventory
e. Difference

N/A
173,797.00
N/A
0
N/A

f. Explanation of difference
1. Program change

f. Explanation of difference
1. Program change

Required to obtain or retain benefits

b.

Mandatory
c.
14. Annual reporting and recordkeeping cost burden(in thousands of dollars)

2. Adjustment

N/A
N/A

N/A
N/A

2. Adjustment
15. Purpose of information collection (Mark primary with "P" and all others

16. Frequency of recordkeeping or reporting(check all that apply)
a. ✔ Recordkeeping

that apply with "X")
a. __ Application for benefits

e. __ Program planning or management c.

b. __ Program evaluation

f. __ Research

c. __ General purpose statistics g. P
__ Regulatory or compliance
d. __ Audit

b.

Third party disclosure

Reporting:
1.

On occasion

2.

Weekly

4.
7.

Quarterly
Biennially

5.
8.

Semi-annually 6.
Annually
Other (describe) ____________

3.

Monthly

18. Agency contact (person who can best answer questions regarding the content

17. Statistical methods
Does this information collection employ statistical methods?
Yes

No ✔

of this submission)
Gerry Lynn Brovey, Supervisory Information Liaison Specialist
Name: ______________________________________________________

(304) 625-4320
Phone: ______________________________________________________
OMB 83-I

10/95