Application for Dependency and Indemnity Compensation, Death Pension and Accrued Benefits by a Surviving Spouse or Child (Including Death Compensation if Applicable)
ICR 200403-2900-009
OMB: 2900-0004
Federal Form Document
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 2900-0004 can be found here:
Application for Dependency
and Indemnity Compensation, Death Pension and Accrued Benefits by a
Surviving Spouse or Child (Including Death Compensation if
Applicable)
No
material or nonsubstantive change to a currently approved
collection
This form is used to gather
information to determine spouse's and children's eligibility,
dependency and income, as applicable, for the death benefits
sought.
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.