Information Collection

Health Benefits Registration Form (fehbp), Health Benefits Enrollment Change Form, Enrollment Code Form & Brochure Request Form, & Enrollment Change Form

IC 156939 under ICR 198708-3206-003 · OMB 3206-0141.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0141 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	HEALTH BENEFITS REGISTRATION FORM (FEHBP), HEALTH BENEFITS ENROLLMENT CHANGE FORM, ENROLLMENT CODE FORM & BROCHURE REQUEST FORM, & ENROLLMENT CHANGE FORM	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	2809 O/P	No	No
Form	2809-Y	No	No
Form	2809-EZ1	No	No
Form	2809-EZ2	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 285,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	285,500	229,900	55,600
Annual IC Time Burden (Hours)	35,688	28,738	6,950
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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