CLAIM FOR DEATH BENEFITS

ICR 198108-1121-029

OMB: 1121-0024

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
168037 Migrated
ICR Details
1121-0024 198108-1121-029
Historical Active 198102-1121-003
DOJ/OJP
CLAIM FOR DEATH BENEFITS
No material or nonsubstantive change to a currently approved collection   No
Emergency 08/28/1981
Approved with change 08/28/1981
Retrieve Notice of Action (NOA) 08/28/1981
  Inventory as of this Action Requested Previously Approved
12/31/1981 12/31/1981 12/31/1981
700 0 700
7,000 0 7,000
0 0 0

P.L. 94-430, THE PUBLIC SAFETY OFFICERS BENEFITS ACT OF 1976, AUTHORIZES LEAA TO PAY A DEATH BENEFITS TO ELIGIBLE SURVIVORS OF PUBLIC SAFETY OFFICERS WHO DIE IN THE LINE OF DUTY. FORM DETERMINES ELIGIBILITY THROUGH PROVIDING INFORMATION CONCERNING THE SURVIVING RELATIVE OF THE DECEDENT.

None
None


No

1
IC Title Form No. Form Name
CLAIM FOR DEATH BENEFITS OJARS, 3650

  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 700 700 0 0 0 0
Annual Time Burden (Hours) 7,000 7,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
08/28/1981


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