Information Collection

Claim For Death Benefits

IC 12363 under ICR 200611-1121-004 · OMB 1121-0024.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1121-0024 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OJP FORM 3650/5 CLAIM FOR DEATH BENEFITS	Form and Instruction
OJP FORM 3650/5 CLAIM FOR DEATH BENEFITS DEATH BENEFITS CLAIM FORM.pdf www.ojp.usdoj.gov/BJA/grant/psob/psob_main.html	Form and Instruction

IC Title:

CLAIM FOR DEATH BENEFITS

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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 and Instruction	OJP FORM 3650/5	CLAIM FOR DEATH BENEFITS	DEATH BENEFITS CLAIM FORM.pdf	http://www.ojp.usdoj.gov/BJA/grant/psob/psob_main.html	Yes	Yes	Fillable Printable

Line of Business: Law Enforcement

Subfunction: Leadership Protection

Privacy Act System of Records

Title: Privacy Act 1974

FR Citation: 28 FR 22

Number of Respondents: 275

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	275	-45	320
Annual IC Time Burden (Hours)	1,100	620	480
Annual IC Cost Burden (Dollars)	2,578	-422	3,000

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.