Domestic Assurance (Renewal)

Assurance (Interinstitutional, Foreign, and Domestic) and Annual Report (Office of Director)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0765 can be found here:

Documents and Forms

Document Name Document Type
Form 3 Domestic Assurance (Renewal) Form and Instruction
3 Domestic Assurance Domestic Assurance.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Domestic Assurance (Renewal)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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
Form and Instruction	3	Domestic Assurance	Domestic Assurance.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 220	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	220	220
Annual IC Time Burden (Hours)	5,720	5,720
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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