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 17^th^ Street NW         |                                     |
| > Washington, DC 20503**.      |                                     |
+--------------------------------+-------------------------------------+
| 1.  Agency/Subagency           | 2\. OMB control number b. None      |
|     originating request        |                                     |
|                                | a\. \_\_ \_\_ \_\_ \_\_ - \_\_ \_\_ |
|                                | \_\_ \_\_ \_\_ \_\_ \_\_ \_\_       |
+--------------------------------+-------------------------------------+
| 3\. Type of information        | 4\. Type of review requested (check |
| collection (check one)         | one)                                |
|                                |                                     |
| a.   New Collection            | a.   Regular                        |
|                                |                                     |
| b.   Revision of a currently   | b.   Emergency -- Approval          |
|     approved collection        |     requested by \_\_/\_\_/\_\_     |
|                                |                                     |
| c.   Extension of a currently  | c.   Delegated                      |
|     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 OMB control    |                                     |
|     number                     |                                     |
|                                |                                     |
| For b-f, note item A2 of       |                                     |
| Supporting Statement           |                                     |
| instructions                   |                                     |
+--------------------------------+-------------------------------------+
|                                | 5\. Small entities                  |
|                                |                                     |
|                                | > Will this information collection  |
|                                | > have a significant economic       |
|                                | > impact on a substantial number of |
|                                | > small entities?                   |
|                                |                                     |
|                                | Yes No                              |
+--------------------------------+-------------------------------------+
|                                | 5.  6\. Requested expiration date   |
|                                |                                     |
|                                | > a\. Three years from approval     |
|                                | > date b. Other \_\_/\_\_           |
+--------------------------------+-------------------------------------+
| 6.  7\. Title                  |                                     |
+--------------------------------+-------------------------------------+
| 8\. Agency form number(s) (if  |                                     |
| applicable)                    |                                     |
+--------------------------------+-------------------------------------+
| 9.  Keywords                   |                                     |
+--------------------------------+-------------------------------------+
| 10. Abstract                   |                                     |
+--------------------------------+-------------------------------------+
| 11. Affected public (Mark      | 12. Obligation to respond (Mark     |
|     primary with "P" and all   |     primary with "P" and all others |
|     others that apply with     |     that apply with "X")            |
|     "X")                       |                                     |
|                                |     a.  \_\_\_ Voluntary            |
| a\. \_\_\_ Individuals or      |                                     |
| households d. \_\_ Farms       |     b.  \_\_\_ Required to obtain   |
|                                |         or retain benefits          |
| b\. \_\_\_ Business or other   |                                     |
| for-profit e. \_\_ Federal     |     c.  \_\_\_ Mandatory            |
| Government                     |                                     |
|                                |                                     |
| c\. \_\_\_ Not-for-profit      |                                     |
| institutions f. \_\_ State,    |                                     |
| Local or Tribal Government     |                                     |
+--------------------------------+-------------------------------------+
| 13. Annual reporting and       | 14. Annual reporting and            |
|     recordkeeping hour burden  |     recordkeeping cost burden (in   |
|                                |     thousands of dollars)           |
|     a.  Number of respondents  |                                     |
|         \_\_\_\_\_\_\_\_\_     | > a\. Total annualized              |
|                                | > capital/startup costs             |
|     b.  Total annual responses | > \_\_\_\                           |
|         \_\_\_\_\_\_\_\_       | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                | >                                   |
| > 1\. Percentage of these      | > b\. Total annual costs (O&M)      |
| > responses                    | > \_\_\                             |
| >                              | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| > collected electronically     | >                                   |
| > \_\_\_\_\_\_\_\_%            | > c\. Total annualized cost         |
| >                              | > requested                         |
| > c\. Total annual hours       | > \_\_\                             |
| > requested \_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| >                              | >                                   |
| > d\. Current OMB inventory    | > d\. Current OMB inventory         |
| > \_\_\_\_\_\_\_\_\_           | > \_\_\_\                           |
| >                              | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| > e\. Difference               | >                                   |
| > \_\_\_\_\_\_\_\_\_\_         | > e\. Difference                    |
| >                              | > \_\_\_\                           |
| > f\. Explanation of           | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| > difference                   | >                                   |
| >                              | > f\. Explanation of difference     |
| > 1\. Program change           | >                                   |
| > \_\_\_\_\_\_\_\_\_\_\_       | > 1\. Program change                |
| >                              | > \_\_\_\_\                         |
| > 2\. Adjustment               | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| > \_\_\_\_\_\_\_\_\_\_\_       | >                                   |
|                                | > 2\. Adjustment                    |
|                                | > \_\_\_\_\                         |
|                                | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+--------------------------------+-------------------------------------+
| 15. Purpose of information     | 16\. Frequency of recordkeeping or  |
|     collection (Mark primary   | reporting (check all that apply)    |
|     with "P" and all others    |                                     |
|     that apply with "X")       | a.   Recordkeeping b. Third party   |
|                                |     disclosure                      |
| a\. \_\_ Application for       |                                     |
| benefits e. \_\_ Program       | > c\. Reporting                     |
| planning or management         | >                                   |
|                                | > 1\. On occasion 2. Weekly 3.      |
| b\. \_\_ Program evaluation f. | > Monthly                           |
| \_\_ Research                  | >                                   |
|                                | > 4\. Quarterly 5. Semi-annually 6. |
| c\. \_\_ General purpose       | > Annually                          |
| statistics g. \_\_ Regulatory  | >                                   |
| or compliance                  | > 7\. Biennially 8. Other           |
|                                | > (describe)                        |
| d\. \_\_ Audit                 | >                                   |
|                                |  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+--------------------------------+-------------------------------------+
| 17. Statistical methods        | 18. Agency contact (person who can  |
|                                |     best answer questions regarding |
| > Does this information        |     the content of this submission) |
| > collection employ            |                                     |
| > statistical methods?         | Name:                               |
| >                              | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_  |
| > Yes No                       | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|                                | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                |                                     |
|                                | 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.      |                      |
| > Their 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) 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  |                      |
| > items below and explain the reason in Item  |                      |
| > 18 of the Supporting Statement.             |                      |
+-----------------------------------------------+----------------------+
| Signature of Senior Official or Designee      | Date                 |
+-----------------------------------------------+----------------------+

**OMB 83-I 10/95**

**Instructions For Completing OMB Form 83-I**

**10/95**