Donor Certification Form

Forms and Documents

Document Name	Status
Form DI-3680 State, Local or Tribal Government Form	Modified
Form DI-3680 Businesses and Organizations Form	Modified
Form DI-3680 Individuals and Households Form	Modified
30-day FR notice.pdf Supplementary Document	2012-07-17
1090-0009 60 Day-77 FR 18850 - 3-28-12.pdf Supplementary Document	2012-07-10
Donor Certification Form SS-A-7-17-12.docx Supporting Statement A	2012-07-17
374 DM 6.htm Supplementary Document	2009-03-12
18 USC 201.pdf Supplementary Document	2009-01-27
9 Stat. at L. 395-7.pdf Supplementary Document	2009-01-27

IC Document Collections

IC ID	Document Title	Status
187613	State, Local or Tribal Government Form	Modified
187612	Businesses and Organizations Form	Modified
187609	Individuals and Households Form	Modified

ICR Details

OMB Control No: 1090-0009	ICR Reference No: 201205-1090-001
Status: Historical Active	Previous ICR Reference No: 200812-1090-001
Agency/Subagency: DOI/ASPMB	Agency Tracking No:
Title: Donor Certification Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/06/2012
	Date Received in OIRA: 07/17/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2015	36 Months From Approved	09/30/2012
Responses	552	0	552
Time Burden (Hours)	184	0	184
Cost Burden (Dollars)	0	0	0

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Abstract: The form is used to screen proposed donations to the Department, or a bureau, valued over $25,000, the point at which a risk analysis showed having such a written form was advisable. The form permits the proposed donor to provide very basic information regarding the circumstances of the gift, including whether given on behalf of another, any current relationship with the Department, or any desired uses of the gift. This supports the Departmental policy to ensure that the acceptance of a gift does not create legal or ethical issues for the Department.

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Authorizing Statute(s): Statute at Large: 9 Stat. 395 Name of Statute: An Act to Establish the Home Department
   US Code: 18 USC 201 Name of Law: Bribery, Graft, and Conflicts of Interest
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 18850	03/28/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 42000	07/17/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
State, Local or Tribal Government	DI-3680	Donor Certification Form
Individuals and Households	DI-3680	Donor Certification Form
Businesses and Organizations	DI-3680	Donor Certification Form

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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	552	552	0	0	0	0
Annual Time Burden (Hours)	184	184	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $23,212

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 07/17/2012

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