Fidelity Bonding Issuance Form

OMB Control Number 1205-0541

Expires 05-31-2023

FIDELITY BONDING ISSUANCE FORM

BOND ID NUMBER: Dropdown List of Bonds Purchased by the State Available for Issue

SECTION I. STATE BONDING COORDINATOR

Name _____________________________________________

Address: _____________________________________

City: _______________________________ State: _________ Zip Code: ________

SECTION II. EMPLOYER RECEIVING BOND

Company Name: ­­­­­­­­­­­­­­­­­­­______________________________________

Contact Person: ______________________________________

Street Address: _____________________________ City: ________________

State: Dropdown List Zip Code: ____________

Occupation Title of Job to be Filled ___________________

Hourly Wage __________ Hours per Week _________

Industry: Dropdown List

• Agriculture, Forestry

• Business and Home Support Services

• Construction

• Education

• Finance and Insurance

• Government

• Health Care

• Lodging and Food Service

• Manufacturing

• Mining or Oil and Gas Extraction

• Professional, Scientific, and Technical

• Retail Trade

• Social Programs

• Transportation and Warehousing

• Utilities

• Wholesale Trade

Employer Type: Dropdown List

• Private for-profit

• Private non-profit

• Public sector

Number of

Employees: Dropdown List

• Less than 20

• 21-50

• 51-100

• Over 100

Bond Effective Date: _____________ Total Amount of Loss Coverage: __________________

SECTION III. WORKER COVERED BY BOND

First Name ___________________________ Last Name ______________________________

Street Address ______________________________________

City ________________________________ State: Dropdown List Zip Code _________

Gender: Dropdown List

• Male

• Female

• Did Not Self-Identify

Hispanic/Latino Ethnicity: Dropdown List

• Yes

• No

Race: Dropdown List

• American Indian/Alaska Native

• Asian

• Black or African American

• Native Hawaiian/Pacific Islander

• White

Privacy Act Statement

The federal bonding program is authorized under Section 169 of the Workforce Innovation and Opportunity Act.  The purpose of the information collected here is to issue a bond covering an employer and employee under the Federal Bonding Program.  The name of the employee covered by the bond and the name, address, and contact person of the employer are necessary for a bond to be issued.  Without the name of the employee and the name and address of the employer a bond cannot be issued.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information, which is required to obtain benefits (PL 105 220 Sections 185 and 186), is estimated to average 12 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employment and Training Administration, OWI, Division of Youth Services, c/o Mallery Johnson, Washington, D.C. 20210 (Paperwork Reduction Project 1205-0541) at Johnson.Mallery@dol.gov. Note: Please do not return the completed Fidelity Bond Issuance Form to this address.