View Information Collection (IC)

View Information Collection (IC)

IC Title:	Consumer Response Intake Form (Paper/Telephone)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Phone Script			Phone Script Intake 3170-0011 DRAFT 2-24-2012.docx		Yes	No	Printable Only
Form	TDF 104.3	Consumer Response Intake Form	Paper Intake Form Mock Up Revised Privacy Statement OMB 6-11-2012.pdf		Yes	No	Printable Only
Other-Telephone Intake with Payday Lending			Attachment 2 Telephone Scripts Payday Intake Form 3170_0011.docx		No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Economic Development

Subfunction: Industry Sector Income Stabilization

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 750,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	750,000	0	0	0	0	750,000
Annual IC Time Burden (Hours)	125,000	0	0	0	0	125,000
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Prior version of the Intake Form	Paper_Version_Intake_Form_Mock_Up_OMB_No_3170-0011_REVISED_2_14_2012_NOT_IN_USE.pdf	06/13/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.