Information Collection

Application for Survivor Insurance Annuities

IC 33834 under ICR 200703-3220-004 · OMB 3220-0030.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0030 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AA-17B Application for Survivor Insurance Annuities	Form
AA-17 Application for Widow(er)'s Annuity Form AA-17 (04-04).pdf	Form
AA-17B Application for Determination of Widow(ers) Disability Form AA-17b (06-04).pdf	Form
AA-18 Application for Mother's/Father's and Child Annuity Form AA-18 (04-04).pdf	Form
AA-19 Application for Child's Annuity Form AA-19 (05-04).pdf	Form
AA-19A Application for Determination of Child's Disability Form AA-19 (05-04).pdf	Form
AA-20 Application for Parent's Annuity Form AA-20 (04-04).pdf	Form
AA-17 (proposed) Application for Widow(ers) Annuity Form AA-17 (proposed).pdf	Form and Instruction
AA-17b (proposed) Application for Determination of Widow(ers) Disability Form AA-17b (proposed).pdf	Form
AA-18 (proposed) Application for Mother's/Father's and Child Annuity AA-18 (Proposed).pdf	Form
AA-19 (proposed) Application for Child's Annuity Form AA-19 (proposed).pdf	Form
AA-20 (proposed) Application for Parent's Annuity Form AA-20 (proposed).pdf	Form
AA-17cert Application Summary and Certification AA-17cert(Allpossible).pdf	Form
AA-17cert Application Summary and Certification AA-17cert(Samplecompleted).pdf	Form
Form RB-3 (08-04).pdf RB-3 Booklet; Furnishing Evidence to Support Your Claim	IC Document
Form RB-17 (07-04).pdf RB-17 Booklet, Survivor Annuities	IC Document
Form RB-17b (08-04).pdf RB-17b Booklet; Widow(ers) Disability Benefits	IC Document
RB-19a (5-99).pdf RB-19A Booklet; Child's Disability Benefits	IC Document
AA-17rec.pdf AA-17rec; Receipt for Claim	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Application for Survivor Insurance Annuities

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 218 20 CFR 219 20 CFR 216 20 CFR 217

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	AA-17B	Application for Determination of Widow(ers) Disability	Form AA-17b (06-04).pdf	No	Paper Only
Form	AA-18	Application for Mother's/Father's and Child Annuity	Form AA-18 (04-04).pdf	No	Paper Only
Form	AA-19	Application for Child's Annuity	Form AA-19 (05-04).pdf	No	Paper Only
Form	AA-19A	Application for Determination of Child's Disability	Form AA-19 (05-04).pdf	No	Paper Only
Form	AA-20	Application for Parent's Annuity	Form AA-20 (04-04).pdf	No	Paper Only
Form and Instruction	AA-17 (proposed)	Application for Widow(ers) Annuity	Form AA-17 (proposed).pdf	No	Paper Only
Form	AA-17b (proposed)	Application for Determination of Widow(ers) Disability	Form AA-17b (proposed).pdf	No	Paper Only
Form	AA-18 (proposed)	Application for Mother's/Father's and Child Annuity	AA-18 (Proposed).pdf	No	Paper Only
Form	AA-19 (proposed)	Application for Child's Annuity	Form AA-19 (proposed).pdf	No	Paper Only
Form	AA-20 (proposed)	Application for Parent's Annuity	Form AA-20 (proposed).pdf	No	Paper Only
Form	AA-17cert	Application Summary and Certification	AA-17cert(Allpossible).pdf	No	Paper Only
Form	AA-17cert	Application Summary and Certification	AA-17cert(Samplecompleted).pdf	No	Paper Only
Form	AA-17	Application for Widow(er)'s Annuity	Form AA-17 (04-04).pdf	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System

FR Citation: 40 FR 36268

Number of Respondents: 4,137

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 79 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	4,137	4,137
Annual IC Time Burden (Hours)	1,718	1,718
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
RB-3 Booklet; Furnishing Evidence to Support Your Claim	Form RB-3 (08-04).pdf	08/01/2004
RB-17 Booklet, Survivor Annuities	Form RB-17 (07-04).pdf	07/01/2004
RB-17b Booklet; Widow(ers) Disability Benefits	Form RB-17b (08-04).pdf	08/02/2004
RB-19A Booklet; Child's Disability Benefits	RB-19a (5-99).pdf	05/03/1999
AA-17rec; Receipt for Claim	AA-17rec.pdf	07/03/2006

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