Personal Injury Compensation Form

September 11th Victim Compensation Fund Claimant Registration Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1105-0092 can be found here:

Documents and Forms

Document Name Document Type
Form XXXX Personal Injury Compensation Form Form and Instruction
XXXX Personal Injury Compensatin Form PI Compensation Form - unformatted.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Personal Injury Compensation Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	XXXX	Personal Injury Compensatin Form	PI Compensation Form - unformatted.doc		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 31,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	31,500	31,500
Annual IC Time Burden (Hours)	535,500	535,500
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.