Information Collection

Public Safety Officers' Death Benefits Application

IC 227411 under ICR 202010-1121-003 · OMB 1121-0220.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1121-0220 can be found here:

Documents and Forms

Document Name Document Type
death part A.xlsx Other-questions
Death part A with required docs.xlsx Other-questions that require documen
death part B.xlsx Other-questions
Death part B with required docs.xlsx Other-questions that require documen

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Public Safety Officers' Death Benefits Application	Agency IC Tracking Number:	BJA

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-questions	death part A.xlsx	n/a	Yes	Yes	Fillable Fileable
Other-questions that require documents	Death part A with required docs.xlsx	n/a	Yes	Yes	Fillable Fileable
Other-questions	death part B.xlsx	n/a	Yes	Yes	Fillable Fileable
Other-questions that require documents	Death part B with required docs.xlsx	n/a	Yes	Yes	Fillable Fileable

Line of Business: Education

Subfunction: Higher Education

Privacy Act System of Records
Title:	FR Citation:

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

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	350	350
Annual IC Time Burden (Hours)	2,100	2,100
Annual IC Cost Burden (Dollars)	0	0

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.