Financial Capability Form

Forms and Documents

Document Name	Status
Form 1122-XXXX Financial Capability Form Form	New
VAWA13.pdf Supplementary Document	2016-06-20
vawa2000.pdf Supplementary Document	2016-06-20
vawa2005.pdf Supplementary Document	2016-06-20
vawa.pdf Supplementary Document	2016-06-20
20 CFR REGS.docx Supplementary Document	2016-06-20
1122-NEW Fin Cap Sup State_062116.doc Supporting Statement A	2016-06-21

IC Document Collections

IC ID	Document Title	Status
222054	Financial Capability Form Form	New

ICR Details

OMB Control No: 1122-0030	ICR Reference No: 201606-1122-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOJ/OVW	Agency Tracking No: 1122-XXXX
Title: Financial Capability 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 without change	Conclusion Date: 09/01/2016
	Date Received in OIRA: 06/21/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2019	36 Months From Approved
Responses	40	0	0
Time Burden (Hours)	160	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: In accordance with 2 CFR 200.205, the Office on Violence Against Women is seeking information required for assessing the financial risk of an applicant’s ability to administer federal funds. The form includes a mix of check box and narrative questions related to the organization’s financial systems, policies and procedures. The affected public includes non-governmental applicants to OVW grant programs that do not currently (or within the last 3 years) have funding from OVW.

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Authorizing Statute(s): US Code: 42 USC 13925, et seq. Name of Law: Violence Against Women Act
  

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:
	81 FR 6293	02/05/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 20673	04/08/2016
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Financial Capability Form	1122-XXXX	Financial Capability 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	40	0	0	40	0	0
Annual Time Burden (Hours)	160	0	0	160	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: In accordance with 2 CFR 200.205, the Office on Violence Against Women is seeking information required for assessing the financial risk of an applicant’s ability to administer federal funds. The form includes a mix of check box and narrative questions related to the organization’s financial systems, policies and procedures. The affected public includes non-governmental applicants to OVW grant programs that do not currently (or within the last 3 years) have funding from OVW. A similar version of this form was approved by OMB for use by the Office of Justice Programs. Previously, OVW used that OJP form which has since been discontinued by OJP.

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Annual Cost to Federal Government: $2,240

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: 06/21/2016

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