83-i

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

3. Type of information collection (check one)
b.

✔

New Collection

a. ✔ Regular

Revision of a currently approved collection

b.

Emergency - Approval requested by: ____/____/____

c.

Delegated

5. Small entities

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

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

collection for which approval has expired

Yes

Existing collection in use without an OMB control number

f.

__ __ __ __

4. Type of review requested (check one)

c. ✔ Extension of a currently approved collection
Reinstatement, without change, of a previously approved
d.
e.

None

__ __ __ __ - __0052
__ __ __
a. __ 1110

FBI/CJIS
a.

b.

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

Identity History Summary Request Form
8. Agency form number(s) (if applicable)

1-783
9. Keywords

Identity History Summary Request
10. Abstract
DOJ's CJIS is requesting PRA approval for an revision of a currently approved collection used by individuals to request a copy of their personal identification
record to view it or to obtain a change, correction, or update to the 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

b. P Required to obtain or retain benefits

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

Mandatory
c.
14. Annual reporting and recordkeeping cost burden(in thousands of dollars)
a. Total annualized capital/startup costs

125,000
125,000

b. Total annual costs (O&M)

1. Percentage of these responses

c. Total annualized cost requested

N/A
c. Total annual hours requested 10,417
0
d. Current OMB inventory
150,000
e. Difference

%

collected electronically

d. Current OMB inventory
e. Difference
f. Explanation of difference
1. Program change

f. Explanation of difference
1. Program change

2. Adjustment

X
N/A

X
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. __ Application for benefits

Recordkeeping
e. __ Program planning or management c. ✔ Reporting:

b. __ Program evaluation

f. __ Research

that apply with "X")

N/A
299,375.00
N/A
566,765
267,390

a.

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

1. ✔ On occasion
4.
7.

Quarterly
Biennially

b.

Third party disclosure

2.

Weekly

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

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) If 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 (see note in Item 19 of the instructions);
(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 below and explain the reason in
Item 18 of the Supporting Statement.

Signature of Senior Official or designee

OMB 83-I

Date

10/95