View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1405-0250
ICR Reference No:
202601-1110-001CF
Status:
Active
Previous ICR Reference No:
202304-1110-001CF
Agency/Subagency:
DOJ/FBI
Agency Tracking No:
Title:
ELIGIBILITY QUESTIONNAIRE FOR HAVANA ACT PAYMENTS-FBI
Type of Information Collection:
RCF Recertification
Common Form ICR:
Type of Review Request:
OIRA Conclusion Action:
Approved
Conclusion Date:
01/07/2026
Retrieve Notice of Action (NOA)
Date Received in OIRA:
01/07/2026
Terms of Clearance:
DOJ is authorized to make only minor changes to the host IC to make it usable for DOJ claimants. This includes changing agency seals, updating addresses, etc. Any substantive change that modifies the information being collected in any way falls outside of the common form approval and is prohibited.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
01/31/2026
01/31/2026
01/31/2026
Responses
25
0
25
Time Burden (Hours)
13
0
13
Cost Burden (Dollars)
0
0
0
Abstract:
Authorizing Statute(s):
PL:
Pub.L. 117 - 46 1828
Name of Law: The Havana Act of 2021
Citations for New Statutory Requirements:
PL: Pub.L. 117 - 46 1828 Name of Law: HAVANA Act of 2021
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Eligibility Questionnaire For HAVANA Act Payments
DS-4316, DS-4316
Eligibility Questionnaire for Havana Act Payments
,
Eligibility Questionnaire for HAVANA Act payments
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
25
25
0
0
0
0
Annual Time Burden (Hours)
13
13
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Changing Regulations
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
Does this IC contain surveys, censuses, or employ statistical methods?
Does this ICR request any personally identifiable information (see
OMB Circular No. A-130
for an explanation of this term)? Please consult with your agency's privacy program when making this determination.
Does this ICR include a form that requires a Privacy Act Statement (see
5 U.S.C. §552a(e)(3)
)? Please consult with your agency's privacy program when making this determination.
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?
No
Agency Contact:
Myaa Amoah 202 693-4566 amoah.myaa@dol.gov
Common Form ICR:
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
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 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.
(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 by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
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