OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death

ICR 201201-3206-010 · OMB 3206-0172 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form SF 3104B Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death Form and Instruction Modified Repair queued
Justification_SF3104B.doc Justification for No Material/Nonsubstantive Change Uploaded 2012-01-09 Available
SF3104B_November2010_Markup.pdf Supplementary Document Uploaded 2012-01-09 Repair queued
SF3104B_April2012_MarkUp.pdf Supplementary Document Uploaded 2012-01-09 Repair queued
SF 3104 SS.doc Supporting Statement A Uploaded 2010-06-22 Available
IC Document Collections
IC IDCollectionTypeStatusForm
33651 Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death Form and Instruction Modified
ICR Details
3206-0172 201201-3206-010
Historical Active 201006-3206-004
OPM
Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 01/27/2012
Retrieve Notice of Action (NOA) 01/26/2012
  Inventory as of this Action Requested Previously Approved
09/30/2013 09/30/2013 09/30/2013
16,751 0 16,751
16,751 0 16,751
0 0 0
SF 3104B, Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death, is used by applicants for death benefits under FERS if the deceased was a Federal employee at the time of death. We have made several editorial changes to the SF 3104B including but not restricted to: Basic Employee Death Benefit rates, Roth IRA, and etc. SF 3104B has been revised to inform applicants of these changes.
US Code: 5 USC Chapter 84 Name of Law: Federal Employees Retirement System
  
None
Not associated with rulemaking
  74 FR 67255 12/18/2009
75 FR 35091 06/21/2010
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 16,751 16,751 0 0 0 0
Annual Time Burden (Hours) 16,751 16,751 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$332,675
No
No
No
No
No
Uncollected
Miles Windsor 202 606-8358 [email protected]
  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.
01/26/2012