Information Collection

Claim for Death Benefits

IC 12363 under ICR 201605-1121-001 · OMB 1121-0024.

Documents and Forms

Document Name Document Type
Form 3650/5 Claim for Death Benefits Form
3650/5 Claim for Death Benefits DEATH BENEFITS CLAIM FORM.pdf www.psob.gov Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claim for Death Benefits	Agency IC Tracking Number:	BJA

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3650/5	Claim for Death Benefits	DEATH BENEFITS CLAIM FORM.pdf	www.psob.gov	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 350	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	350	30	320
Annual IC Time Burden (Hours)	700	220	480
Annual IC Cost Burden (Dollars)	3,281	281	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.