Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity and Temporary Continuation of Coverage Enrollees.

ICR 199507-3206-001

OMB: 3206-0202

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
3206-0202 199507-3206-001
Historical Active 199407-3206-001
OPM
Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity and Temporary Continuation of Coverage Enrollees.
Extension without change of a currently approved collection   No
Regular
Approved without change 09/25/1995
Retrieve Notice of Action (NOA) 07/13/1995
  Inventory as of this Action Requested Previously Approved
09/30/1998 09/30/1998 09/30/1995
28,000 0 0
4,700 0 2,500
0 0 0

DPRS 2809 is used by annuitants and former spouses who are eligible to elect, cancel, or change health benefits enrollment during open season.

None
None


No

1
IC Title Form No. Form Name
Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity and Temporary Continuation of Coverage Enrollees. DPRS-2809

  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 28,000 0 0 0 28,000 0
Annual Time Burden (Hours) 4,700 2,500 0 0 2,200 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.
07/13/1995


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