Claim For Death Benefits -- OMB No. 1121-0024

ICR 200109-1121-004

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
38350 Migrated
ICR Details
1121-0024 200109-1121-004
Historical Active 199903-1121-005
DOJ/OJP
Claim For Death Benefits -- OMB No. 1121-0024
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 09/14/2001
Retrieve Notice of Action (NOA) 09/14/2001
  Inventory as of this Action Requested Previously Approved
05/31/2002 05/31/2002 05/31/2002
820 0 320
925 0 800
0 0 0

This form is used to submit claims for benefits under the PSOB Act. The form is completed by the eligible survivors of public safety officers killed in the line of duty.

None
None


No

1
IC Title Form No. Form Name
Claim For Death Benefits -- OMB No. 1121-0024 3650/5, (REV-10-95)

  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 820 320 0 500 0 0
Annual Time Burden (Hours) 925 800 0 125 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
09/14/2001


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