Information Collection

Claim For Death Benefits

IC 12363 under ICR 200611-1121-004 · OMB 1121-0024.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1121-0024 can be found here:

Documents and Forms

Document Name Document Type
Form OJP FORM 3650/5 CLAIM FOR DEATH BENEFITS Form and Instruction
OJP FORM 3650/5 CLAIM FOR DEATH BENEFITS DEATH BENEFITS CLAIM FORM.pdf www.ojp.usdoj.gov/BJA/grant/psob/psob_main.html Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CLAIM FOR DEATH BENEFITS	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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	OJP FORM 3650/5	CLAIM FOR DEATH BENEFITS	DEATH BENEFITS CLAIM FORM.pdf	http://www.ojp.usdoj.gov/BJA/grant/psob/psob_main.html	Yes	Yes	Fillable Printable

Line of Business: Law Enforcement

Subfunction: Leadership Protection

Privacy Act System of Records
Title: Privacy Act 1974	FR Citation: 28 FR 22

Number of Respondents: 275	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	275	-45	320
Annual IC Time Burden (Hours)	1,100	620	480
Annual IC Cost Burden (Dollars)	2,578	-422	3,000

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.