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Federal forms, ICRs, and supporting documents

Information Collection Request

Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants

ICR 200412-3206-002 · OMB 3206-0202 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC IDCollectionTypeStatusForm
33692 Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants Form Migrated
ICR Details
3206-0202 200412-3206-002
Historical Active 200207-3206-004
OPM
Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants
Revision of a currently approved collection   No
Regular
Approved without change 03/15/2005
Retrieve Notice of Action (NOA) 12/13/2004
  Inventory as of this Action Requested Previously Approved
03/31/2008 03/31/2008 03/31/2005
27,000 0 27,000
20,250 0 20,250
0 0 0
The Direct Pay Remittance System (DPRS) 2809 is used by enrollees under the Spouse Equity and Temporary Continuation of Coverage provisions of FEHB law, and by annuitants who pay their premiums directly to the retirement system. During the annual FEHB open season, these enrollees use this form to change their enrollment or request plans brochures.
None
None
No
  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 27,000 27,000 0 0 0 0
Annual Time Burden (Hours) 20,250 20,250 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
12/13/2004