Combined Federal Campaign (CFC) Form 1654-B (Retiree Pledge Form)

OMB Control No: 3206-0271	ICR Reference No: 201711-3206-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: OPM	Agency Tracking No: OPM 1654B
Title: Combined Federal Campaign (CFC) Form 1654-B (Retiree Pledge Form)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/04/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/03/2017
Terms of Clearance: This form is approved based on the revised materials provided by the Agency.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2020	36 Months From Approved
Responses	250,000	0	0
Time Burden (Hours)	125,000	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Abstract: The Combined Federal Campaign (CFC) is the world’s largest and most successful annual workplace philanthropic giving campaign. The mission of the CFC is to promote and support philanthropy through a program that is employee-focused, cost-efficient, and effective in providing all federal employees the opportunity to improve the quality of life for all. With the signing of Executive Order 13743 on October 13, 2016, authorizing the solicitation of federal annuitants, the Combined Federal Campaign Annuitant Pledge Form will be used to collect and process federal annuitant and military retirees’ pledges through the Combined Federal Campaign.

---

Authorizing Statute(s): EO: EO 13743 Name/Subject of EO: Charitable Fundraising

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 39918	08/22/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 50169	10/30/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title Form No. Form Name Annuitant Pledge Form

---

ICR Summary of Burden

	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	250,000	0	0	250,000	0	0
Annual Time Burden (Hours)	125,000	0	0	125,000	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new EO and IC never authorized in the past. Will monitor public burden during this authorization. FRN Citation for SORN will be edited when available.

---

Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Charles Conyers 202 606-0125 [email protected]

---

Common Form ICR:  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:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(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;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
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.
Certification Date: 11/03/2017

---