omb-83i - Guam - Signed Final (002)

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

2. OMB control number
a. 1105

Department of Justice/Foreign Claims Settlement Commission
3. Type of information collection (check one)

b.

None

-

4. Type of review requested (check one)

a. ✔ New collection

a. ✔ Regular

b.

Revision of a currently approved collection

b.

Emergency - Approval requested by:

c.

Delegated

c.

Extension of a currently approved collection

d.

Reinstatement, without change, of a previously approved
collection for which approval has expired

e.

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

f.

Existing collection in use without an OMB control number

5. Small entities
Will this information collection have a significant economic impact on
a substantial number of small entities?
Yes
✔ No
6. Requested expiration date
a. ✔ Three years from approval date b.

For b-f, note item A2 of Supporting Statement instructions.

Other Specify:

7. Title

Statement of Claim for filing of Claims in the Guam Claims Program Pursuant to the Guam World War II Loyalty Recognition Act
8. Agency form number(s) (if applicable)

FCSC - 2
9. Keywords

Foreign Claims, Guam, World War II, Personal Injury, Death, Internment
10. Abstract

DOJ’s Foreign Claims Settlement Commission is requesting PRA approval of a new collection that would request
information regarding the injuries suffered by individuals as a result of the attack and occupation of Guam by Imperial
Japanese military forces during World War II, or incident to the liberation of Guam by United States military forces for
the purpose of obtaining compensation pursuant to the Guam World War II Loyalty Recognition Act, Title XVII,
Public Law 114-328 (December 23, 2016).

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

P

Individuals or households

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

Farms

a.

b.

Business or other for-profit e.

Federal Government

b.

c.

Not-for-profit institutions

State, Local or Tribal Government

c.

d.
f.

5,000
5,000

b. Total annual responses
1. Percentage of these
responses collected electronically
c. Total annual hours requested

0
10,000
0

d. Current OMB inventory

$1
$0
$1
$0
$1

b. Total annual costs (O&M)
c. Total annualized cost requested

%

d. Current OMB inventory
e. Difference
f. Explanation of difference

New Program

1. Program change

f. Explanation of difference
1. Program change

Mandatory

a. Total annualized capital/startup costs

10000

e. Difference

Required to obtain or retain benefits

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

13. Annual reporting and recordkeeping hour burden
a. Number of respondents

Voluntary

P

2. Adjustment

New Program

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

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

Recordkeeping
c. ✔ Reporting

b.

Third party disclosure

Application for benefits

e.

Program planning or
management

b.

Program evaluation

f.

Research

1.

On occasion

2.

Weekly

c.

General purpose statistics

g.

Regulatory or compliance

4.

Quarterly

5.

Semi-annually 6.

d.

Audit

7.

Biannually

8.

a.

P

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

✔ No

✔

3.

Other (describe)

Monthly
Annually

One Time

18. Agency contact (person who can best answer questions regarding the content
of this submission)

Name:

Jeremy LaFrancois
Signature (Management Board or designee)

Phone:
OMB 83-I

(202) 616-6975
10/95

This form was electronically produced by Elite Federal Forms, Inc.

Go

19. Certification for Paperwork Reduction Act Submissions
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with
5 CFR 1320.9.
NOTE: The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8 (b) (3), appear at the end of the
instructions. The certification is to be made with reference to those regulatory provisions as set forth in
the instructions.
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 terminology 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):
(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 of 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 (see note in Item 19 of the instructions);
(i) It uses effective and efficient statistical survey methodology; and
(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item below and explain the reason
in Item 18 of the Supporting Statement.

Signature of Authorized Agency Official

BRIAN SIMKIN
Signature of Senior Official or designee

Digitally signed by BRIAN SIMKIN
DN: c=US, o=U.S. Government, ou=Dept of
Justice, ou=FCSC, cn=BRIAN SIMKIN,
0.9.2342.19200300.100.1.1=15001000115072
Date: 2017.02.07 11:09:00 -05'00'

Date

2/7/2017
Date

2/3/2017
OMB 83-I

10/95

Instructions For Completing OMB Form 83-I
Please answer all questions and have the Senior
Official or designee sign the form. These instructions should be used in conjunction with 5 CFR
1320, which provides information on coverage, definitions, and other matters of procedure and interpretation under the Paperwork Reduction Act of 1995.
1.

5.

Indicate whether this information collection
will have a significant impact on a substantial
number of small entities. A small entity may
be (1) a small business which is deemed to be
one that is independently owned and operated
and that is not dominant in its field of operation; (2) a small organization that is any notfor-profit enterprise that is independently
owned and operated and is not dominant in its
field; or (3) a small government jurisdiction
which is a government of a city, county, town,
township, school district, or special district
with a population of less than 50,000.

Agency/Subagency originating request
Provide the name of the agency or subagency
originating the request. For most cabinet-level
agencies, a subagency designation is also necessary. For non-cabinet agencies, the subagency designation is generally unnecessary.

2.

OMB control number

6.

a. If the information collection in this request
has previously received or now has an OMB
control or comment number, enter the number.
b. Check "None" if the information collection
in this request has not previously received an
OMB control number. Enter the four digit
agency code for your agency.
3.

Type of information collection (check one)
a. Check "New collection" when the collection has not previously been used or sponsored by the agency.
b. Check "Revision" when the collection is
currently approved by OMB, and the agency
request includes a material change to the collection instrument, instructions, its frequency
of collection, or the use to which the information is to be put.
c. Check "Extension" when the collection is
currently approved by OMB, and the agency
wishes only to extend the approval past the
current expiration date without making any
material change in the collection instrument,
instructions, frequency of collection, or the
use to which the information is to be put.
d. Check "Reinstatement without change"
when the collection previously had OMB
approval, but the approval as expired or was
withdrawn before this submission was made,
and there is not change to the collection.
e. Check "Reinstatement with change" when
the collection previously has OMB approval,
but the approval has expired or was withdrawn before this submission was made, and
there is change to the collection.
f. Check "Existing collection in use without
OMB control number" when the collection is
currently in use but does not have a currently
valid OMB control number.

4.

Type of review requested (check one)
a. Check "Regular" when the collection is
submitted under 5 CFR 1320.10, 1320.11,
or 1320.12 with a standard 60 day review
schedule.
b. Check "Emergency" when the agency is
submitting the request under 5 CFR 1320.13
for emergency processing and provides the
required supporting material. Provide the date
by which the agency requests approval.
c. Check "Delegated" when the agency is
submitting the collection under the conditions
OMB has granted the agency delegated
authority.

Small entities

7.

b. Enter the number of responses provided
annually. For recordkeeping as compared to
reporting activity, the number of responses
equals the number of recordkeepers.

Requested expiration date
a. Check "Three years" if the agency requests
a three year approval for the collection.

c. Enter the total annual recordkeeping and
reporting hour burden.

b. Check "Other" if the agency requests
approval for less than three years. Specify
the month and year of the requested expiration
date.

d. Enter the burden hours currently approved
by OMB for this collection of information.
Enter zero (0) for any new submission or for
any collection whose OMB approval has
expired.

Title

Agency form number(s) (if applicable)
Provide any form number the agency has
assigned to this collection of information.
Separate each form number with a comma.

9.

a. Enter the number of respondents and/or
recordkeepers. If a respondent is also a recordkeeper, report the respondent only once.

b1. Enter the estimated percentage of responses that will be submitted/collected electronically using magnetic media (i.e., diskette),
electronic mail, or electronic data interaction.
Facsimile is not considered an electronic
submission.

Provide the official title of the information
collection. If an official title does not exist,
provide a description which will distinguish
this collection from others.
8.

13. Annual reporting and recordkeeping
hour burden

Keywords
Select and list at least two keywords (descriptors) from the "Federal Register Thesaurus of
Indexing Terms" that describe the subject
area(s) of the information collection. Other
terms may be used but should be listed after
those selected from the thesaurus. Separate
keywords with commas. Keywords should
not exceed two lines of text.

10. Abstract
Provide a statement, limited to five lines of
text, covering the agency's need for the information, uses to which it will be put, and a
brief description of the respondents.
11. Affected public
Mark all categories that apply, denoting the
primary public with a "P" and all others that
apply with "X".
12. Obligation to respond
Mark all categories that apply, denoting the
primary obligation with a "P" and all others
that apply with "X".
a. Mark "Voluntary" when the response is
entirely discretionary and has no direct effect
on any benefit or privilege for the respondent.
b. Mark "Required to obtain or retain benefits" when the response is elective, but is
required to obtain or retain a benefit.
c. Mark "Mandatory" when the respondent
must reply or face civil or criminal sanctions.

e. Enter the difference by subtracting line d
from line c. Record a negative number (d larger than c) within parentheses.
f. Explain the difference. The difference in
line e must be accounted for in lines f1 and f2.
f1. "Program change" is the result of deliberate Federal government action. All new collections and any subsequent revision of existing collections (e.g. the addition or deletion of
questions) are recorded as program changes.
f2. "Adjustment" is a change that is not the
result of a deliberate Federal government
action. Changes resulting from new estimates
or actions not controllable by the Federal government are recorded as adjustments.
14. Annual reporting and recordkeeping cost
burden (in thousands of dollars)
The costs identified in this item must exclude
the cost of hour burden identified
in Item 13.
a. Enter total dollar amount of annualized
cost for all respondents of any associated capital or start-up costs.
b. Enter recurring annual dollar amount of
cost form all respondents associated with operating or maintaining systems or purchasing
services.
c. Enter total (14a + 14b) annual reporting
and recordkeeping cost burden.
d. Enter any cost burden currently approved
by OMB for this collection of information.
Enter zero (0) if this is the first submission
after October 1, 1995.
e. Enter the difference by subtracting line d
from line c. Record a negative number (d larger than c) within parentheses.
f. Explain the difference. The difference in
line e must be accounted for in lines f1 and f2.
f1. "Program change" is the result of deliberate Federal government action. All new collections and any subsequent revision or
changes resulting in cost changes are recorded
as program changes..
10/95

f2. "Adjustment" is a change that is not the
result of a deliberate Federal government
action. Changes resulting from new estimations or actions not controllable by the Federal
government are recorded as adjustments.
15. Purpose of information collection
Mark all categories that apply, denoting the
primary purpose with a "P" and all others that
apply with "X".
a. Mark "Application for benefits" when the
purpose is to participate in, receive, or qualify
for a grant, financial assistance, etc, from a
Federal agency or program.
b. Mark "Program evaluation" when the purpose is a formal assessment, through objective
measures and systematic analysis, of the manner and extent to which Federal programs
achieve their objectives or produce other
significant effects.
c. Mark "General purpose statistics" when
the data is collected chiefly for use by the
public or for general government use, without
primary reference to the policy or program
operations of the agency collecting the data.
d. Mark "Audit" when the purpose is to verify the accuracy of accounts and records.
e. Mark "Program planning or management"
when the purpose relates to progress reporting
and grants management, procurement and

qualify control or other administrative
information that does not fit into any other
category.
f. Mark "Research" when the purpose is to
further the course of research, rather than for
a specific program purpose.
g. Mark "Regulatory or compliance" when
the purpose is to measure compliance with
laws or regulations.
16. Frequency of recordkeeping or reporting
Check "Recordkeeping" if the collection of
information explicitly includes a recordkeeping requirement.
Check "Third party disclosure" if a collection
of information includes third-party disclosure
requirements as defined by 1320.3 (c).
Check "Reporting" for information collections
that involve reporting and check the frequency
of reporting that is requested or required of a
respondent. If the reporting is on "an event
basis", check "On occasion".
17. Statistical methods
Check "Yes" if the information collection
uses statistical methods such as sampling or
imputation. Generally, check "No" for applications and audits (unless a random auditing
scheme is used). Check "Yes" for statistical
collections, most research collections, and scientific program evaluations. For other types of

data collection, the use of sampling, imputation, or other statistical estimation techniques
should dictate the response for this item.
Ensure that supporting documentation is provided in accordance with Section B of the
Supporting Statement.
18. Agency contact
Provide the name and telephone number of
the agency person best able to answer questions regarding the content of this submission.
19. Certification for Paperwork Reduction
Act Submission
The Senior Official or designee signing this
statement certifies that the collection of information encompassed by the request complies
with 5 CFR 1320.9. Provisions of this certification that the agency cannot comply with
should be identified and fully explained in
item 18 of the attached Supporting Statement.
NOTE: The Office that "develops" and
"uses" the information to be collected is the
office that "conducts or sponsors" the collection of information. (See 5 CFR 1320.3(d).

10/95

Supporting Statement for Paperwork Reduction Act Submissions
•

General Instructions
A Supporting Statement, including the text of the
notice to the public required by 5 CFR
1320.5(a)(i)(iv) and its actual or estimated date of
publication in the Federal Register, must
accompany each request for approval of a
collection of information. The Supporting
Statement must be prepared in the format
described below, and must contain the
information specified in Section A below. If an
item is not applicable, provide a brief
explanation. When Item 17 of the OMB Form
83-I is checked "Yes", Section B of the
Supporting Statement must be completed. OMB
reserves the right to require the submission of
additional information with respect to any request
f
l

•

•

•

Specific Instructions

•

A. Justification
1.

2.

3.

4.

Explain the circumstances that make the
collection of information necessary. Identify
any legal or administrative requirements
that necessitate the collection. Attach a copy
of the appropriate section of each statute
and regulation mandating or authorizing the
collection of information.
Indicate how, by whom, and for what
purpose the information is to be used.
Except for a new collection, indicate the
actual use the agency has made of the
information received from the current
Describe whether, and to what extent, the
collection of information involves the use of
automated, electronic, mechanical, or other
technological collection techniques or other
forms of information technology, e.g.
permitting electronic submission of
responses, and the basis for the decision for
adoption this means of collection. Also
describe any consideration of using
information technology to reduce burden.

If the collection of information impacts
small businesses or other small entities
(Item 5 of OMB Form 83-I), describe any
methods used to minimize burden.

6.

Describe the consequence to Federal
program or policy activities if the collection
is not conducted or is conducted less
frequently, as well as any technical or legal
obstacles to reducing burden
Explain any special circumstances that
would cause an information collection to be
conducted in a manner:
•

•

•

requiring respondents to report
information to the agency more often
than quarterly;
requiring respondents to prepare a
written response to a collection of
information in fewer than 30 days after
receipt of it;
requiring respondents to submit more
than an original and two copies of any
document;

9.

12.

If applicable, provide a copy and identify the
date and page number of publication in the
Federal Register of the agency's notice,
required by 5 CFR 1320.8 (d), soliciting
comments on the information collection
prior to submission to OMB. Summarize
public comments received in response to that
notice and describe actions taken by the
agency in response to these comments.
Specifically address comments received on
cost and hour burden.

Provide estimates of the hour burden of the
collection of information. The statement
should:
•

that includes a pledge of confidentiality
that is not supported by authority
established in statue or regulation, that is
not supported by disclosure and data
security policies that are consistent with
the pledge, or which unnecessarily
impedes sharing of data with other
agencies for compatible confidential use;
or
requiring respondents to submit
proprietary trade secret, or other
confidential information unless the
agency can demonstrate that it has
instituted procedures to protect the
information's confidentiality to the
extent permitted by law.

Describe efforts to consult with persons
outside the agency to obtain their views on
the availability of data, frequency of
collection, the clarity of instructions and
record keeping, disclosure, or reporting
format (if any), and on the data elements to
be recorded, disclosed, or reported.

Describe efforts to identify duplication.
Show specifically why any similar
information already available cannot be
used or modified for use for the purposes
described in Item 2 above

5.

7.

8.

requiring respondents to retain records.
other than health, medical, government
contract, grant-in-aid, or tax records for
more than three years;
in connection with a statistical survey,
that is not designed to produce valid and
reliable results that can be generalized to
the universe of study;
requiring the use of a statistical data
classification that has not been reviewed
and approved by OMB;

•

•

13.

Describe any assurance of confidentiality
provided to respondents and the basis for the
assurance in statute, regulation, or agency
policy.

11.

Provide additional justification for any
questions of a sensitive nature, such as
sexual behavior and attitudes, religious
beliefs, and other matters that are commonly
considered private. This justification should
include the reasons why the agency
considers the questions necessary, the
specific uses to be made of the information,
the explanation to be given to persons from
whom the information is requested, and any
steps to be taken to obtain their consent.

Provide estimates of annualized cost to
respondents for the hour burdens for
collections of information, identifying
and using appropriate wage rate
categories. The cost of contraction out
or paying outside parties for
information collection activities should
not be included here. Instead, this cost
should be included in Item 14.

Provide an estimate of the total annual cost
burden to respondents or record keepers
resulting from the collection of information.
(Do not include the cost of any hour burden
shown in Items 12 and 14).
•

Consultation with representatives of those
from whom information is to be obtained or
those who must compile records should
occur at least once every 3 years-even if the
collection of information activity is the same
as in prior periods. There may be
circumstances that may preclude
consultation in a specific situation. These
circumstances should be explained
Explain any decision to provide any payment
or gift to respondents, other than
re-enumeration of contractors or grantees.

10.

Indicate the number of respondents,
frequency of response, annual hour
burden, and an explanation of how the
burden was estimated. Unless directed
to do so, agencies should not conduct
special surveys to obtain information
on which to base hour burden
estimates. Consultation with a sample
(fewer than 10) of potential
respondents is desirable. If the hour
burden on respondents is expected to
vary widely because of differences in
activity, size, or complexity, show the
range of estimated hour burden, and
explain the reasons for the variance.
Generally, estimates should not include
burden hours for customary and usual
business practices
If this request for approval covers more
than one form, provide separate hour
burden estimates for each form and
aggregate the hour burdens in Item 13
of OMB Form 83-I.

•

The cost estimate should be split into
two components: (a) a total capital and
start-up cost component (annualized
over its expected useful life); and (b) a
total operation and maintenance and
purchase of services component. The
estimates should take into account costs
associated with generating,
maintaining, and disclosing or
providing the information. Include
descriptions of methods used to
estimate major cost factors including
system and technology acquisition,
expected useful life of capital
equipment, the discount rate(s), and the
time period over which costs will be
incurred. Capital and start-up costs
include, among other items,
preparations for collecting information
such as purchasing computers and
software; monitoring, sampling, drilling
and testing equipment; and record
f ili i
If cost estimates are expected to vary
widely, agencies should present ranges
of cost burdens and explain the reasons
for the variance. The cost of purchasing
or contracting out information
collection services should be a part of
this cost burden estimate. In developing
cost burden estimates, agencies may
10/95

consult with a sample of respondents
(fewer than 10), utilize the 60-day
pre-OMB submission public comment
process and use existing economic or
regulatory impact analysis associated
with the rulemaking containing the
information collection as appropriate.
•

14.

15.

16.

Generally, estimates should not include
purchases of equipment or services, or
portions thereof, made: (1) prior to
October 1, 1995, (2) to achieve
regulatory compliance with requirements
not associated with the information
collection, (3) for reasons other than to
provide information or keep records for
the government, or (4) as part of
customary and usual business or private
practices.
Provide estimates of annualized cost to the
Federal government. Also, provide a
description of the method used to estimate
cost, which should include quantification of
hours, operational expenses (such as
equipment, overhead, printing, and support
staff), and any other expense that would not
have been incurred without this collection
of information. Agencies also may
aggregate cost estimates from Items 12, 13,
and 14 in a single table.
Explain the reasons for any program
changes or adjustments reported in Items 13
or 14 of the OMB Form 83-I
For collections of information whose results
will be published, outline plans for
tabulation, and publication. Address any
complex analytical techniques that will be
used. Provide the time schedule for the
entire project, including beginning and
ending dates of the collection of
information, completion of report
publication dates, and other actions.

17.

18.

If seeking approval to not display the
expiration date for OMB approval of the
information collection, explain the reasons
that display would be inappropriate.

•

Explain each exception to the certification
statement identified in Item 19,
"Certification for Paperwork Reduction
Act Submissions," of OMB Form 83-I.

•

B. Collections of Information Employing
Statistical Methods
The agency should be prepared to justify its
decision not to use statistical methods in any case
where such methods might reduce burden or
improve accuracy of results. When Item 17 on the
Form OMB 83-I is checked "Yes", the following
documentation should be included in the
Supporting Statement to the extent that it applies
to the methods proposed:
1. Describe (including a numerical estimate)
the potential respondent universe and any
sampling or other respondent selection
method to be used. Data on the number of
entities (e.g., establishments, State and local
government units, households, or persons)
in the universe covered by the collection
and in the corresponding sample are to be
provided in tabular form for the universe as
a whole and for each of the strata in the
proposed sample. Indicate expected
response rates for the collection as a whole.
If the collection had been conducted
previously, include the actual response rate
achieved during the last collection.
2.

Describe the procedures for the collection
of information including:

•
•

•

Statistical methodology for
stratification and sample selection,
Estimation procedure,
Degree of accuracy needed for the
purpose described in the justification,
Unusual problems requiring specialized
sampling procedures, and
Any use of periodic (less frequent than
annual) data collection cycles to reduce
burden.

3.

Describe methods to maximize response
rates and to deal with issues of
non-response. The accuracy and reliability
of information collected must be shown to
be adequate for intended uses. For
collections based on sampling, a special
justification must be provided for any
collection that will not yield "reliable" data
that can be generalized to the universe

4.

Describe any tests of procedures or methods
to be undertaken. Testing is encouraged as
an effective means of refining collections of
information to minimize burden and
improve utility. Tests must be approved if
they call for answers to identical questions
from 10 or more respondents. A proposed
test or set of tests may be submitted for
approval separately or in combination with
the main collection of information.

5.

Provide the name and telephone number of
individuals consulted on statistical aspects
of the design and the name of the agency
unit, contractor(s), grantee(s), or other
person(s) who will actually collect and/or
analyze the information for the agency

10/95

ATTACHMENT A
AUTHORIZING LEGISLATION NECESITATING
INFORMATION COLLECTION

S. 2943—643
(i) a list and description of the covered GPS devices
that are being or expected to be interfered with by
commercial communications services;
(ii) a description of the source of, and the entity
causing or expected to cause, the interference with
such devices;
(iii) a description of the manner in which such
source or such entity is causing or expected to cause
such interference;
(iv) a description of the magnitude of harm caused
or expected to be caused by such interference;
(v) a description of the duration of and the conditions and circumstances under which such interference
is occurring or expected to occur;
(vi) a description of the impact of such interference
on the national security interests of the United States;
and
(vii) a description of the plans of the Secretary
to address, alleviate, or mitigate such interference,
including the cost of such plans.
(C) FORM.—The notice required under subparagraph
(A) shall be submitted in unclassified form, but may include
a classified annex.
(3) TERMINATION DATE.—The date referred to in this paragraph is the earlier of—
(A) the date that is two years after the date of the
enactment of this Act; or
(B) the date on which the Secretary—
(i) determines that commercial communications
services are not causing any widespread harmful interference with covered GPS devices; and
(ii) submits to the congressional defense committees notice of the determination made under clause
(i).
(c) COVERED GPS DEVICE DEFINED.—In this section, the term
‘‘covered GPS device’’ means a Global Positioning System device
of the Department of Defense.
(d) CONFORMING REPEAL.—Section 911 of the National Defense
Authorization Act for Fiscal Year 2012 (Public Law 112–81; 125
Stat. 1534) is repealed.

TITLE XVII—GUAM WORLD WAR II
LOYALTY RECOGNITION ACT
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.

1701.
1702.
1703.
1704.
1705.
1706.

Short title.
Recognition of the suffering and loyalty of the residents of Guam.
Guam World War II Claims Fund.
Payments for Guam World War II claims.
Adjudication.
Grants program to memorialize the occupation of Guam during World
War II.
Sec. 1707. Authorization of appropriations.
SEC. 1701. SHORT TITLE.

This title may be cited as the ‘‘Guam World War II Loyalty
Recognition Act’’.

S. 2943—644
SEC. 1702. RECOGNITION OF THE SUFFERING AND LOYALTY OF THE
RESIDENTS OF GUAM.

(a) RECOGNITION OF THE SUFFERING OF THE RESIDENTS OF
GUAM.—The United States recognizes that, as described by the
Guam War Claims Review Commission, the residents of Guam,
on account of their United States nationality, suffered unspeakable
harm as a result of the occupation of Guam by Imperial Japanese
military forces during World War II, by being subjected to death,
rape, severe personal injury, personal injury, forced labor, forced
march, or internment.
(b) RECOGNITION OF THE LOYALTY OF THE RESIDENTS OF
GUAM.—The United States forever will be grateful to the residents
of Guam for their steadfast loyalty to the United States, as demonstrated by the countless acts of courage they performed despite
the threat of death or great bodily harm they faced at the hands
of the Imperial Japanese military forces that occupied Guam during
World War II.
SEC. 1703. GUAM WORLD WAR II CLAIMS FUND.

(a) ESTABLISHMENT OF FUND.—The Secretary of the Treasury
shall establish in the Treasury of the United States a special
fund (in this title referred to as the ‘‘Claims Fund’’) for the payment
of claims submitted by compensable Guam victims and survivors
of compensable Guam decedents in accordance with sections 1704
and 1705.
(b) COMPOSITION OF FUND.—The Claims Fund established
under subsection (a) shall be composed of amounts deposited into
the Claims Fund under subsection (c) and any other payments
made available for the payment of claims under this title.
(c) PAYMENT OF CERTAIN DUTIES, TAXES, AND FEES COLLECTED
FROM GUAM DEPOSITED INTO FUND.—
(1) IN GENERAL.—Notwithstanding section 30 of the Organic
Act of Guam (48 U.S.C. 1421h), the excess of—
(A) any amount of duties, taxes, and fees collected
under such section after fiscal year 2014, over
(B) the amount of duties, taxes, and fees collected
under such section during fiscal year 2014,
shall be deposited into the Claims Fund.
(2) APPLICATION.—Paragraph (1) shall not apply after the
date for which the Secretary of the Treasury determines that
all payments required to be made under section 1704 have
been made.
(d) LIMITATION ON PAYMENTS MADE FROM FUND.—
(1) IN GENERAL.—No payment may be made in a fiscal
year under section 1704 until funds are deposited into the
Claims Fund in such fiscal year under subsection (c).
(2) AMOUNTS.—For each fiscal year in which funds are
deposited into the Claims Fund under subsection (c), the total
amount of payments made in a fiscal year under section 1704
may not exceed the amount of funds available in the Claims
Fund for such fiscal year.
(e) DEDUCTIONS FROM FUND FOR ADMINISTRATIVE EXPENSES.—
The Secretary of the Treasury shall deduct from any amounts
deposited into the Claims Fund an amount equal to 5 percent
of such amounts as reimbursement to the Federal Government
for expenses incurred by the Foreign Claims Settlement Commission
and by the Department of the Treasury in the administration

S. 2943—645
of this title. The amounts so deducted shall be covered into the
Treasury as miscellaneous receipts.
SEC. 1704. PAYMENTS FOR GUAM WORLD WAR II CLAIMS.

(a) PAYMENTS FOR DEATH, PERSONAL INJURY, FORCED LABOR,
FORCED MARCH, AND INTERNMENT.—After the Secretary of the
Treasury receives the certification from the Chairman of the Foreign
Claims Settlement Commission as required under section
1705(b)(8), the Secretary of the Treasury shall make payments,
subject to the availably of appropriations, to compensable Guam
victims and survivors of a compensable Guam decedents as follows:
(1) COMPENSABLE GUAM VICTIM.—Before making any payments under paragraph (2), the Secretary shall make payments
to compensable Guam victims as follows:
(A) In the case of a victim who has suffered an injury
described in subsection (c)(2)(A), $15,000.
(B) In the case of a victim who is not described in
subparagraph (A), but who has suffered an injury described
in subsection (c)(2)(B), $12,000.
(C) In the case of a victim who is not described in
subparagraph (A) or (B), but who has suffered an injury
described in subsection (c)(2)(C), $10,000.
(2) SURVIVORS OF COMPENSABLE GUAM DECEDENTS.—In the
case of a compensable Guam decedent, the Secretary shall
pay $25,000 for distribution to survivors of the decedent in
accordance with subsection (b). The Secretary shall make payments under this paragraph only after all payments are made
under paragraph (1).
(b) DISTRIBUTION OF SURVIVOR PAYMENTS.—A payment made
under subsection (a)(2) to the survivors of a compensable Guam
decedent shall be distributed as follows:
(1) In the case of a decedent whose spouse is living as
of the date of the enactment of this Act, but who had no
living children as of such date, the payment shall be made
to such spouse.
(2) In the case of a decedent whose spouse is living as
of the date of the enactment of this Act and who had one
or more living children as of such date, 50 percent of the
payment shall be made to the spouse and 50 percent shall
be made to such children, to be divided among such children
to the greatest extent possible into equal shares.
(3) In the case of a decedent whose spouse is not living
as of the date of the enactment of this Act and who had
one or more living children as of such date, the payment shall
be made to such children, to be divided among such children
to the greatest extent possible into equal shares.
(4) In the case of a decedent whose spouse is not living
as of the date of the enactment of this Act and who had
no living children as of such date, but who—
(A) had a parent who is living as of such date, the
payment shall be made to the parent; or
(B) had two parents who are living as of such date,
the payment shall be divided equally between the parents.
(5) In the case of a decedent whose spouse is not living
as of the date of the enactment of this Act, who had no living
children as of such date, and who had no parents who are
living as of such date, no payment shall be made.

S. 2943—646
(c) DEFINITIONS.—For purposes of this title:
(1) COMPENSABLE GUAM DECEDENT.—The term ‘‘compensable Guam decedent’’ means an individual determined under
section 1705 to have been a resident of Guam who died as
a result of the attack and occupation of Guam by Imperial
Japanese military forces during World War II, or incident to
the liberation of Guam by United States military forces, and
whose death would have been compensable under the Guam
Meritorious Claims Act of 1945 (Public Law 79–224) if a timely
claim had been filed under the terms of such Act.
(2) COMPENSABLE GUAM VICTIM.—The term ‘‘compensable
Guam victim’’ means an individual who is not deceased as
of the date of the enactment of this Act and who is determined
under section 1705 to have suffered, as a result of the attack
and occupation of Guam by Imperial Japanese military forces
during World War II, or incident to the liberation of Guam
by United States military forces, any of the following:
(A) Rape or severe personal injury (such as loss of
a limb, dismemberment, or paralysis).
(B) Forced labor or a personal injury not under
subparagraph (A) (such as disfigurement, scarring, or
burns).
(C) Forced march, internment, or hiding to evade
internment.
(3) DEFINITIONS OF SEVERE PERSONAL INJURIES AND PERSONAL INJURIES.—Not later than 180 days after the date of
the enactment of this Act, the Foreign Claims Settlement
Commission shall promulgate regulations to specify the injuries
that constitute a severe personal injury or a personal injury
for purposes of subparagraphs (A) and (B), respectively, of
paragraph (2).
SEC. 1705. ADJUDICATION.

(a) AUTHORITY OF FOREIGN CLAIMS SETTLEMENT COMMISSION.—
(1) IN GENERAL.—The Foreign Claims Settlement Commission shall adjudicate claims and determine the eligibility of
individuals for payments under section 1704.
(2) RULES AND REGULATIONS.—Not later than 180 days
after the date of the enactment of this Act, the Chairman
of the Foreign Claims Settlement Commission shall publish
in the Federal Register such rules and regulations as may
be necessary to enable the Commission to carry out the functions of the Commission under this title.
(b) CLAIMS SUBMITTED FOR PAYMENTS.—
(1) SUBMITTAL OF CLAIM.—For purposes of subsection (a)(1)
and subject to paragraph (2), the Foreign Claims Settlement
Commission may not determine an individual is eligible for
a payment under section 1704 unless the individual submits
to the Commission a claim in such manner and form and
containing such information as the Commission specifies.
(2) FILING PERIOD FOR CLAIMS AND NOTICE.—
(A) FILING PERIOD.—An individual filing a claim for
a payment under section 1704 shall file such claim not
later than one year after the date on which the Foreign
Claims Settlement Commission publishes the notice
described in subparagraph (B).

S. 2943—647
(B) NOTICE OF FILING PERIOD.—Not later than 180
days after the date of the enactment of this Act, the Foreign
Claims Settlement Commission shall publish a notice of
the deadline for filing a claim described in subparagraph
(A)—
(i) in the Federal Register; and
(ii) in newspaper, radio, and television media in
Guam.
(3) ADJUDICATORY DECISIONS.—The decision of the Foreign
Claims Settlement Commission on each claim filed under this
title shall—
(A) be by majority vote;
(B) be in writing;
(C) state the reasons for the approval or denial of
the claim; and
(D) if approved, state the amount of the payment
awarded and the distribution, if any, to be made of the
payment.
(4) DEDUCTIONS IN PAYMENT.—The Foreign Claims Settlement Commission shall deduct, from a payment made to a
compensable Guam victim or survivors of a compensable Guam
decedent under this section, amounts paid to such victim or
survivors under the Guam Meritorious Claims Act of 1945
(Public Law 79–224) before the date of the enactment of this
Act.
(5) INTEREST.—No interest shall be paid on payments made
by the Foreign Claims Settlement Commission under section
1704.
(6) LIMITED COMPENSATION FOR PROVISION OF REPRESENTATIONAL SERVICES.—
(A) LIMIT ON COMPENSATION.—Any agreement under
which an individual who provided representational services
to an individual who filed a claim for a payment under
this title that provides for compensation to the individual
who provided such services in an amount that is more
than one percent of the total amount of such payment
shall be unlawful and void.
(B) PENALTIES.—Whoever demands or receives any
compensation in excess of the amount allowed under
subparagraph (A) shall be fined not more than $5,000
or imprisoned not more than one year, or both.
(7) APPEALS AND FINALITY.—Objections and appeals of
decisions of the Foreign Claims Settlement Commission shall
be to the Commission, and upon rehearing, the decision in
each claim shall be final, and not subject to further review
by any court or agency.
(8) CERTIFICATIONS FOR PAYMENT.—After a decision
approving a claim becomes final, the Chairman of the Foreign
Claims Settlement Commission shall certify such decision to
the Secretary of the Treasury for authorization of a payment
under section 1704.
(9) TREATMENT OF AFFIDAVITS.—For purposes of section
1704 and subject to paragraph (2), the Foreign Claims Settlement Commission shall treat a claim that is accompanied by
an affidavit of an individual that attests to all of the material
facts required for establishing the eligibility of such individual
for payment under such section as establishing a prima facie

S. 2943—648
case of the eligibility of the individual for such payment without
the need for further documentation, except as the Commission
may otherwise require. Such material facts shall include, with
respect to a claim for a payment made under section 1704(a),
a detailed description of the injury or other circumstance supporting the claim involved, including the level of payment
sought.
(10) RELEASE OF RELATED CLAIMS.—Acceptance of a payment under section 1704 by an individual for a claim related
to a compensable Guam decedent or a compensable Guam
victim shall be in full satisfaction of all claims related to
such decedent or victim, respectively, arising under the Guam
Meritorious Claims Act of 1945 (Public Law 79–224), the implementing regulations issued by the United States Navy pursuant
to such Act (Public Law 79–224), or this title.
SEC. 1706. GRANTS PROGRAM TO MEMORIALIZE THE OCCUPATION OF
GUAM DURING WORLD WAR II.

(a) ESTABLISHMENT.—Subject to subsection (b), the Secretary
of the Interior shall establish a grant program under which the
Secretary shall award grants for research, educational, and media
activities for purposes of appropriately illuminating and interpreting
the causes and circumstances of the occupation of Guam during
World War II and other similar occupations during the war that—
(1) memorialize the events surrounding such occupation;
or
(2) honor the loyalty of the people of Guam during such
occupation.
(b) ELIGIBILITY.—The Secretary of the Interior may not award
a grant under subsection (a) unless the person seeking the grant
submits an application to the Secretary for such grant, in such
time, manner, and form and containing such information as the
Secretary specifies.
SEC. 1707. AUTHORIZATION OF APPROPRIATIONS.

(a) GUAM WORLD WAR
TION.—For the purposes of

II CLAIMS PAYMENTS AND ADJUDICAcarrying out sections 1704 and 1705,
there is authorized to be appropriated for any fiscal year beginning
after the date of enactment of this Act, an amount equal to the
amount deposited into the Claims Fund in a fiscal year under
section 1703. Not more than 5 percent of funds make available
under this subsection shall be used for administrative costs.
Amounts appropriated under this section may remain available
until expended.
(b) GUAM WORLD WAR II GRANTS PROGRAM.—For purposes
of carrying out section 1706, there are authorized to be appropriated
$5,000,000 for each fiscal year beginning after the date of the
enactment of this Act.

TITLE XVIII—MATTERS RELATING TO
SMALL BUSINESS PROCUREMENT
Subtitle A—Improving Transparency and Clarity for Small Businesses
Sec. 1801. Plain language rewrite of requirements for small business procurements.
Sec. 1802. Transparency in small business goals.

ATTACHMENT B
DRAFT COLLECTION INSTRUMENT

OMB Approval Number:
Expiration Date:

U.S. DEPARTMENT OF JUSTICE
FOREIGN CLAIMS SETTLEMENT COMMISSION

(FOR FCSC USE ONLY)
CLAIM NO.

STATEMENT OF CLAIM
FOR FILING OF CLAIMS IN THE GUAM CLAIMS PROGRAM PURSUANT TO
THE GUAM WORLD WAR II LOYALTY RECOGNITION ACT, TITLE XVII,
PUBLIC LAW 114-328 (DECEMBER 23, 2016)
CONTACT INFORMATION
1. CLAIMANT
Name of Claimant
(Last)

(First)

(Middle)

(Street Address)

(City)

(State/Territory)

Work Phone

(Zip Code)

Home Phone

Email
Date of Birth

2. LEGAL REPRESENTATIVE (if any)
Name of Legal Representative
(Last)

(First)

(Middle)

Name of Law Firm

(Street Address)

(City)
Phone

(State/Territory)

(Zip Code)

Fax

Email

Paperwork Reduction Act Statement: This information collection has been cleared under the Paperwork Reduction Act of 1995, 44 U.S.C. 3501 et seq. (Control No. XXXXXXXX). Under 44 U.S.C. 3506(c)(1)(B)(iii)(V), an agency may not conduct or sponsor, and a person may not be required to respond to, an information collection request unless
the information collection form bears a valid control number. Completion of this form is mandatory in order to obtain compensation. The estimated burden associated with this
collection of information is 2.0 hours per respondent or recordkeeper.

FORM FCSC-GUAM

BASIC CLAIM INFORMATION
3. TYPE OF CLAIM
I hereby submit a claim for payment under the Guam World War II Loyalty Recognition Act, Title XVII, Public Law 114-328 (December 23,
2016) as a: (check all that apply)
Survivor of a Compensable Guam Decedent
Compensable Guam Victim
4. GUAM RESIDENCY
Have you ever been a resident of Guam?
If the above answer is "Yes," please provide the date(s) of residency (from/to).

5. CLAIM OF SURVIVOR OF COMPENSABLE GUAM DECEDENT
Complete this Section only if you are submitting a claim as a Survivor of a Compensable Guam Decedent.
5.1 Are you a spouse, child, or parent of an individual who died as a result of the attack and occupation of Guam by Imperial
Japanese military forces during World War II, or incident to the liberation of Guam by United States military forces? If so, please
respond to each question below.
5.2 Name of decedent

5.3 Date of death

5.4 Relation to decedent

5.5 Was the decedent a resident of Guam?
5.6 If the answer above is "Yes," please provide the date(s) of residency (from/to).

5.7 Identify all known survivors of the decedent who were living as of December 23, 2016, including, to the extent applicable, the
decedent's spouse, children, and parents.

5.8 Please provide a detailed account of the facts and circumstances relating to the decedent's death. Please specify the cause of the
decedent's death, if known. You may also attach any other evidence that you believe supports your answers to the above questions. (Attach
additional pages as necessary)

6. CLAIM OF COMPENSABLE GUAM VICTIM
Complete this Section only if you are submitting a claim as a Compensable Guam Victim.

6.1 Rape
6.1.1 Were you raped as a result of the attack and occupation of Guam by Imperial Japanese military forces during World War II, or
incident to the liberation of Guam by United States military forces? If so, please respond to each question below.
6.1.2 Please provide the approximate date(s) and location(s) of your injury.

6.1.3 Please provide a detailed account of your injury and the facts and circumstances relating to it. (Attach additional pages as necessary)

6.2 Personal Injury
6.2.1 Did you suffer a personal injury as a result of the attack and occupation of Guam by Imperial Japanese military forces during
World War II, or incident to the liberation of Guam by United States military forces? If so, please respond to each question below.
6.2.2 Please identify the injury that you suffered (check all that apply) and provide the date and place of injury. If your injury is not listed,
please enter it in the space provided at the end of the chart below.

Type of Injury
Dismemberment
Loss of Limb
Paralysis
Disfigurement
Burns
Scarring
Other (please specify)
Other (please specify)

Approximate Date of Injury

Place of Injury

6.2.3 Did your injury require medical treatment?
6.2.4 If the answer is "Yes," where were you treated and what kind of treatment did you receive?

6.2.5 Please provide a detailed description of the nature and extent of your injury, the cause of your injury (if known), and the circumstances
under which it occurred. You may also attach to this claim form any other evidence, including photographic evidence, that you believe
supports your answers to the above questions. (Attach additional pages as necessary)

6.3 Forced Labor
6.3.1 Were you a victim of forced labor as a result of the attack and occupation of Guam by Imperial Japanese military forces during
World War II, or incident to the liberation of Guam by United States military forces? If so, please respond to each question below.

6.3.2 Please provide the approximate date(s) and location(s) where labor was performed.

6.3.3 Please provide your age at the time the labor was performed.

6.3.4 Did you receive compensation for your labor?

6.3.5 Please provide a detailed description of the type of labor that you performed and the conditions you experienced at your place(s) of
labor. Please specify whether your labor had direct relation to war operations. (Attach additional pages as necessary)

6.4 Forced March
6.4.1 Were you a victim of forced march as a result of the attack and occupation of Guam by Imperial Japanese military forces during
World War II, or incident to the liberation of Guam by United States military forces? If so, please respond to each question below.
6.4.2 Please provide the approximate date(s) and location(s) where the forced march took place.

6.4.3 Please provide a detailed account of the facts or circumstances that resulted in the forced march and describe the conditions you
experienced. Please specify the food, water, and clothing rations you received, the number of hours you were required to walk every day,
and the provisions made for overnight or temporary accommodation. (Attach additional pages as necessary)

6.5 Internment
6.5.1 Were you interned as a result of the attack and occupation of Guam by Imperial Japanese military forces during World War II,
or incident to the liberation of Guam by United States military forces? If so, please respond to each question below.
6.5.2 Please provide the approximate date(s) and location(s) of your internment.

6.5.3 Please provide a detailed account of the facts or circumstances relating to your internment and describe the conditions you experienced
while interned. (Attach additional pages as necessary)

6.6 Hiding To Evade Internment
6.6.1 Did you hide to evade internment, as a result of the attack and occupation of Guam by Imperial Japanese military forces during
World War II, or incident to the liberation of Guam by United States military forces? If so, please respond to each question below.
6.6.2 Please provide the approximate date(s) and location(s) of your hiding.

6.6.3 Please provide a detailed account of the facts or circumstances relating to your hiding and describe the conditions you experienced
while in hiding. (Attach additional pages as necessary)

6.7 Level of Payment Sought
Please specify the level of payment sought for your Compensable Guam Victim claim.

7. PRIOR RECEIPT OF COMPENSATION
Have you or anyone else received any compensation from any source with respect to the subject matter of this claim,
including amounts paid under the Guam Meritorious Claims Act of 1945 (Public Law 79-224)?
If the answer is "Yes," state the date of receipt, source, and amount of compensation.

8. RELEASE AND PENALTIES (Each claimant must sign individually. Please make additional copies of this page as necessary.)

RELEASE: The information provided in this Statement of Claim and in any attachments, and any material and information
submitted before or after this Statement of Claim in regard to or in support of the claim, will be treated as public information. The
aforementioned information and materials may be made available to interested persons who make inquiries about the claims program, in
conformity with the Freedom of Information Act. Any decision issued by the Commission in relation to this Statement of Claim will be
made publicly available, including via the Internet. By your signature on this Statement of Claim, you acknowledge that you are aware
of and agree to the making of such disclosures, and that you authorize the Foreign Claims Settlement Commission and its staff to conduct
any investigation needed to decide your claim.
PENALTIES: Your attention is directed to the federal law on false statements, 18 U.S.C. section 1001, which provides:
[W]hoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United
States, knowingly and willfully–
(1) falsifies, conceals or covers up by any trick, scheme, or device a material fact;
(2) makes any false, fictitious, or fraudulent statement or representation; or
(3) makes or uses any false writing or document knowing the same to contain any materially,
fictitious, or fraudulent statement or entry;
shall be fined under [Title 18, U.S. Code] or imprisoned not more than 5 years, or both.
I,

certify that I have read the release and agree to
(Name of Claimant)

its terms. I further certify that, to the best of my knowledge and belief, the statements set forth in this Statement of Claim, including any
papers attached to or filed with this Statement of Claim, are true and accurate, and that all material facts have been set forth in this Statement
of Claim.

Date

Signature of Claimant

Date

Legal Representative Signature

9. FEES LIMITATION (Must be signed by claimant's Legal Representative (if any).)
LEGAL FEES: Your attention is directed to P.L. 114-328 §1705(b)(6)(A), which states: "Any agreement under which an individual

who provided representational services to an individual who filed a claim for a payment under this title that provides for
compensation to the individual who provided such services in an amount that is more than one percent of the total amount of
such payment shall be unlawful and void."
I,

certify that I have read P.L. 114-328 §1705(b)(6), and that I agree to, and I am bound by, its terms.
(Name of Legal Representative)

Date

Legal Representative Signature

Privacy Act Statement
The Foreign Claims Settlement Commission (the Commission) is authorized to collect the information requested on this form (or requested at any other time
regarding this claim) under P.L. 114-328 §1705. The information collected will be used to enable the Commission to carry out its statutory responsibility to
determine the validity and amount of the claims submitted to it under P.L. 114-328 §1705. Furnishing the requested information to the Commission is
voluntary; however, failure to provide such information may result in either the delay of the adjudication or denial of the claim. Information collected may be
disclosed pursuant to routine uses, published at XX Fed. Reg.XXXXX (XX/XX/XXXX). Such routine uses include:
·
To the Department of the Treasury in connection with the payment of claims;
·
To contractors, grantees, experts, consultants, students, and others performing or working on a contract, service, grant, cooperative agreement, or other
assignment for the federal government, when necessary to accomplish an agency function related to this system of records;
·
To a Member of Congress or staff acting upon the Member's behalf when the Member or staff requests the information on behalf of, and at the request of,
the individual who is the subject of the record;
·
Where a record, either alone or in conjunction with other information, indicates a violation or potential violation of law - criminal, civil, or regulatory in
nature - the relevant records may be referred to the appropriate federal, state, local, territorial, tribal, or foreign law enforcement authority or other
appropriate entity charged with the responsibility for investigating or prosecuting such violation or charged with enforcing or implementing such law;
·
In an appropriate proceeding before the Commission, or before a court, grand jury, or administrative or adjudicative body, when the Department of
Justice and/or the Foreign Claims Settlement Commission determines that the records are arguably relevant to the proceeding; or in an appropriate
proceeding before an administrative or adjudicative body when the adjudicator determines the records to be relevant to the proceeding.

ATTACHMENT C
SUPPORTING STATEMENT

DEPARTMENT OF JUSTICE
FOREIGN CLAIMS SETTLEMENT COMMISSION OF THE UNITED STATES
SUPPORTING STATEMENT FOR
REQUEST FOR OMB APPROVAL OF COLLECTION OF INFORMATION
UNDER THE PAPERWORK REDUCTION ACT AND 5 CFR 1320
Guam World War II Loyalty Recognition Program Statement of Claim
OMB Number xxxx-xxxx
FCSC 2
A. Justification

1. This collection of information is needed in order to enable the Foreign Claims Settlement Commission to receive,
examine and adjudicate claims made pursuant to the Guam World War II Loyalty Recognition Act Title XVII,
Public Law 114-328 (December 23, 2016) (the Guam Act).
2. The collected information will be used by the Commission as the basis for determining the validity and amount of
claims oursuant to the Guam Act, and to certify awards resulting from those determinations to the Secretary of the
Treasury for payment out of compensation funds provided for this purpose, in accordance with the Guam Act.
3. The Commission has developed this form to enable claimants or their legal representatives to enter the data
electronically so as to facilitate efficient processing of the claims.
4. The Commission is unaware of any available sources that would contain information similar to that being
requested.
5. This item is not applicable. To the Commission's knowledge, there are no small businesses or other small entities
included among the claimants.
6. If the collection is not conducted, the Commission will be unable to review claims under the Guam Act and
ensure that meritorious claims are compensated.
7. There are no special circumstances associated with this collection.
8. A Federal Register notice has been published to solicit public comment.
9. This item is not applicable.
10. As reflected on the draft Statement of Claim form, the information submitted by the respondents will be subject to
public disclosure under the Freedom of Information Act (5 U.S.C. § 552).

11. Depending on the claim filed, it may be necessary for the Commission to ask questions of a sensitive nature. The
information will be used to adjudicate the claimants’ claims. The claimants will be provided the claim form,
which will make clear that the information requested will be used to adjudicate the claim.
12. Annualized costs of this collection for the respondents will consist merely of postage and photocopying expenses,

which should amount to less than $10 per respondent, and expenditure of their personal time in providing the
information requested. As indicated on the attached Standard Form 83-I, it is estimated that there will be
approximately 5,000 respondents, and that the one-time response will require an average of about two hours of
each respondent's time. This estimate is derived based upon experience in past claims programs where similar
types of information were collected. Using 5,000 respondents as a baseline, we project the total burden to be
approximately 10,000 hours.
13. There will not be any annual cost to respondents or record-keepers associated with capital startup or operation and
maintenance of services resulting from the collection of the information contained in this request .
14. There is no additional cost to the federal government for this collection.
15. Not Applicable.
16. The information from this collection will form the basis for decisions of the Commission. The final decisions of
the Commission will be published on the Commission’s public website pursuant to 5 U.S.C. § 552(a)(2) in due
course.
17. This item is not applicable, as the OMB Approval Number will be displayed on the information collection form.
18. There are no exceptions to the Item 19 Certification at the end of the attached OMB Form 83-I.

B. Collections of Information Employing Statistical Methods.
Not Applicable