Claim for Death Benefits

ICR 200404-1121-001

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
12363
Migrated
ICR Details
1121-0024 200404-1121-001
Historical Active 200310-1121-005
DOJ/OJP
Claim for Death Benefits
Extension without change of a currently approved collection   No
Regular
Approved with change 04/15/2004
Retrieve Notice of Action (NOA) 04/02/2004
  Inventory as of this Action Requested Previously Approved
04/30/2007 04/30/2007 04/30/2004
320 0 320
480 0 480
3,000 0 3,200,000

The Public Safety Officers Benefits (PSOB) Program provides a one-time benefit of $250,000 to the eligible survivors of local, state and federal public safety officers whose deaths result from traumatic injuries substained in the line of duty. The agency requires the information requested on this form to identify survivors and determine their eligibility for the Public Safety Officer Death Benefit in accordance with the statutory requirements found in 42 USC Sec. 3796. Respondents include surviving spouses, children and/or parents of deceased public safety officers.

None
None


No

1
IC Title Form No. Form Name
Claim for Death Benefits

  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 320 320 0 0 0 0
Annual Time Burden (Hours) 480 480 0 0 0 0
Annual Cost Burden (Dollars) 3,000 3,200,000 0 -3,197,000 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.
04/02/2004


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