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OMB Control No: 3095-0058	ICR Reference No: 200402-3095-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: NARA	Agency Tracking No:
Title: Financial Disclosure Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/04/2004
	Date Received in OIRA: 02/13/2004
Terms of Clearance: When approval for this form is sought next year NARA (and specifi cally the Information Security Oversight Office) will provide : - an evaluation of the usability of the form. The evaluation sho uld include agency feedback and take into account the work of the Office of Government Ethics. - a government-wide governance structure for the use, ongoing eva luation and update, education, and dissemination of the form. It should take into account the work of the Office of Personnel Mana gement regarding other standard forms. Per the agreement of involved parties the following modifications of the form and instructions are required. - Section 5 of form: replace $500 with $5000 in the sentence "Do not report capital improvement costs under $500." - On the Additional Entries sheets, instead of "social security n umber" and "social security #" use "personnel identity number." - in the instructions the language used in 10f should also be use d for 11f.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2005	04/30/2005
Responses	25,897	0	0
Time Burden (Hours)	51,794	0	0
Cost Burden (Dollars)	0	0	0

Abstract: This information collection will be used to make personnel security determinations, including whether to grant a security clearance; to allow access to classified information, sensitive areas, and equipment; or to permit assignment to sensitive national security positions. The data may later be used as a part of a review process to evaluate continued eligibility for access to classified information or as evidence in legal proceedings.

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

Federal Register Notices & Comments
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Financial Disclosure Form

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	25,897	25,897
Annual Time Burden (Hours)	51,794	51,794
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

View ICR - OIRA Conclusion