Notice of Death and Statement of Compensation

Employer Reporting

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0005 can be found here:

Documents and Forms

Document Name Document Type
Form AA-12 (xx-xx) Notice of Death and Statement of Compensation Form
AA-12 (09-03) Notice of Death and Statement of Compensation Form AA-12 Current.pdf www.rrb.gov/pdf/aa.12.pdf Form
AA-12 (xx-xx) Notice of Death and Request for Service Needed for Eligi Form AA-12 Proposed.pdf Form

Information Collection (IC) Details

IC Title:	Notice of Death and Statement of Compensation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 209.6

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	AA-12 (xx-xx)	Notice of Death and Request for Service Needed for Eligibility	Form AA-12 Proposed.pdf		No		Paper Only
Form	AA-12 (09-03)	Notice of Death and Statement of Compensation	Form AA-12 Current.pdf	http://www.rrb.gov/pdf/aa.12.pdf	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: RRB-22, Railroad Retirement, Survivor and Pensioner Benfit System	FR Citation: 40 FR 36268

Number of Respondents: 495	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.