Personal Net Worth Form

Uniform Report of DBE Awards/Commitments and other DBE Program Collections

Documents and Forms

Document Name Document Type
Form Appendix G Personal Net Worth Form Form and Instruction
Appendix G Personal Net Worth Statement PNW Statement Tech Corrections Final.docx Form and Instruction
Appendix G Personal Net Worth Statement PNW Statement Tech Corrections Final.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Personal Net Worth Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 49 CFR Part 26 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Appendix G	Personal Net Worth Statement	PNW Statement Tech Corrections Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9,500	Number of Respondents for Small Entity: 9,500

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	9,500	0	9,500
Annual IC Time Burden (Hours)	95,000	76,000	19,000
Annual IC Cost Burden (Dollars)	0	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.