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Agenda
Reg Review
ICR
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:
Modified
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
3170_0011 Revised Paper Intake Form 7-2-2014 (B).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.