Information Collection

Report of Public Safety Officers' Permanent and Total Disability

IC 12434 under ICR 200608-1121-006 · OMB 1121-0166.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1121-0166 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OJP form 3650/7 Report of Public Safety Officers' Permanent and Total Disability	Form
OJP form 3650/7 Public Safety Officer's Benefits Program PSOB_DISABILITY_FORM.pdf www.ojp.usdoj.gov/BJA/grant/psob/psob_main.html	Form

IC Title:

Report of Public Safety Officers' Permanent and Total Disability

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	OJP form 3650/7	Public Safety Officer's Benefits Program	PSOB_DISABILITY_FORM.pdf	http://www.ojp.usdoj.gov/BJA/grant/psob/psob_main.html	Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 75

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	75	30	45
Annual IC Time Burden (Hours)	188	98	90
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.