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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 201409-0505-001 · OMB 0505-0024 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form DPRS 2809 Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants Form and Instruction Modified Available
2011 Markups.pdf Supplementary Document Uploaded 2011-10-11 Available
0505-0024 - 2014 - DPRS2809 SuppStmt.doc Supporting Statement A Uploaded 2014-10-30 Available
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 and Instruction Modified
ICR Details
0505-0024 201409-0505-001
Historical Active 201206-0505-001
USDA/OCFO
Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants
Extension without change of a currently approved collection   No
Regular
Approved with change 04/10/2015
Retrieve Notice of Action (NOA) 10/30/2014
  Inventory as of this Action Requested Previously Approved
04/30/2018 36 Months From Approved 04/30/2015
25,000 0 27,000
18,750 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.
US Code: 5 USC 8905 Name of Law: Health Insurance Election of Coverage
  
None
Not associated with rulemaking
  79 FR 51295 08/28/2014
79 FR 64357 10/29/2014
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 25,000 27,000 0 0 -2,000 0
Annual Time Burden (Hours) 18,750 20,250 0 0 -1,500 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
Due to the Affordable Care Act healthcare options, this submission reflects a reduction of 2,000 enrollees and responses for a decrease in burden of 1,500 hours.
$24,210
No
No
Yes
No
No
Uncollected
Adrianne Riviere 504 426-1311
  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.
10/30/2014