OMB No: 2138-0016, Expiration Date: 7/31/2006
Paperwork Reduction Act Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2138-0016. Public reporting for Form 183, Report of Extension of Credit to Political Candidates, is estimated to be approximately 1 hour per response, including the time for reviewing instructions, completing and reviewing the collection of information. All responses to this collection of information are mandatory. This report is released to the public unless the respondent is granted confidentiality. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Bernie Stankus, OAI/BTS/RITA, RTS-42, Room 4125, 1200 New Jersey Avenue, SE, Washington, D.C. 20590 or e-mail – email@example.com.
Name of Air Carrier _____________________
Month of _____________________
|NAME OF CANDIDATE||Line No.||Name of Account
|Age of Unpaid Bal.
I, the undersigned, (Title) ____________________, of the above-named carrier certify that the above report has been examined by me and to the best of my knowledge and belief is a true, correct and complete report of the period stated.
Date: _____________________ Signature: _____________________
BTS Form 183