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Federal forms, ICRs, and supporting documents

Information Collection Request

Application for Court-Ordered Benefits for Former Spouses, Standard Form 3119

ICR 202008-3206-001 · OMB 3206-0275 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form Standard Form 3119 Application for Court-Ordered Benefits for Former Spouses Form and Instruction New Available
E8-5659.pdf Supplementary Document Uploaded 2020-08-19 Available
ARS PIA Final 12212017signed.pdf Supplementary Document Uploaded 2020-08-19 Available
2020-15455.pdf Supplementary Document Uploaded 2020-08-19 Available
SF3119_60DayFRNPublished_2020_03_23.pdf Supplementary Document Uploaded 2020-08-19 Available
SF3119_OMBSupportingStatement_2020_06_18.docx Supporting Statement A Uploaded 2020-08-19 Available
IC Document Collections
IC IDCollectionTypeStatusForm
243243 Application for Court-Ordered Benefits for Former Spouses Form and Instruction New
ICR Details
3206-0275 202008-3206-001
Active
OPM SF 3119
Application for Court-Ordered Benefits for Former Spouses, Standard Form 3119
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 11/09/2020
Retrieve Notice of Action (NOA) 10/06/2020
  Inventory as of this Action Requested Previously Approved
11/30/2023 36 Months From Approved
19,000 0 0
9,500 0 0
255,229 0 0
5 CFR 838.221, 838.421, and 838.721 require former spouses of Federal employees to write to OPM, providing specific information needed for OPM to make court-ordered benefit payments. This information is needed to identify affected employees and to certify that the court order remains in effect.
US Code: 5 USC 8345(j), 8341(h), 8445, 8467 Name of Law: null
  
None
Not associated with rulemaking
  85 FR 16395 03/23/2020
85 FR 43612 07/17/2020
No
1
IC Title Form No. Form Name
Application for Court-Ordered Benefits for Former Spouses Standard Form 3119 Application for Court-Ordered Benefits for Former Spouses
  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 19,000 0 0 19,000 0 0
Annual Time Burden (Hours) 9,500 0 0 9,500 0 0
Annual Cost Burden (Dollars) 255,229 0 0 255,229 0 0
Yes
Miscellaneous Actions
No
Calculation for Cost Burden
$14,590
No
    Yes
    Yes
No
No
No
No
Charles Conyers 202 606-0125 [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.
10/06/2020