Information Collection

Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants

IC 33692 under ICR 201809-0505-001 · OMB 0505-0024.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0505-0024 can be found here:

Documents and Forms

Document Name Document Type
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
DPRS 2809 Request to Change FEHB or to Receive Plan Brochures for DPRS 2809 Form 2018.pdf Form and Instruction
2011 Markups.pdf 2011 Markups IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants	Agency IC Tracking Number:

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 and Instruction	DPRS 2809	Request to Change FEHB or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitant	DPRS 2809 Form 2018.pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title: OPM/Central-1	FR Citation: 73 FR 15013

Number of Respondents: 25,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25,000	25,000
Annual IC Time Burden (Hours)	18,750	18,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
2011 Markups	2011 Markups.pdf	08/18/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.