Supporting Statement
OMB No. 0730-0011, Physician Certificate for Child Annuitant
JUSTIFICATION
1. According to Department of Defense (DoD) Financial Management Regulation 7000.14-R, Volume 7B, Chapter 35, an annuity may be paid to a third party on behalf of an incapacitated annuitant only if the third party has been appointed as guardian, custodian, or other fiduciary pursuant to a state court order or has been designated a representative payee. Otherwise, the annuity may only be paid to the annuitant unless the annuitant has been determined to be incompetent of managing his or her own affairs by a state court, physician, or psychologist. If the annuity cannot be paid directly to the annuitant or to a third party, amounts will remain unpaid and credited on account until the annuitant is determined to be competent or until a third party has been properly appointed to receive the annuity on behalf of the annuitant. Authority to collect this information is found in Title 10, United States Code, chapters 71 and 73. The Survivor Benefit Plan and the Retired Serviceman’s Family Protection Plan give requirements for coverage of children who are unmarried and incapable of self-support because of mental and/or physical incapacitation.
2. The DD Form 2828 is used by the Directorate of Retired and Annuitant Pay, Defense Finance and Accounting Service – Cleveland (DFAS-CL), to determine proper entitlement of an incapacitated child. The incapacity must be substantiated by a current medical report. If the medical report certifies the disability is permanent, the annuity is payable for the lifetime of the annuitant. If the medical report certifies the disability is temporary, DFAS-CL/PD needs an updated medical certificate every two years to determine proper entitlement and continue annuity payments. If the form with the completed certification is not received, the annuity payments are suspended.
3. The DD form 2828 is available in fillable PDF format or fillable FormFlow versions from the DoD Forms repository on the World Wide Web. Respondents may complete the form online, print and fax or mail the completed form for processing. The DFAS eForms Modernization initiative is in the process of transitioning to electronic data capture from the DFAS web site for all DoD customers.
Investigation resulted in no findings of duplication of reporting or records. No similar
information or verification procedures currently exist that can be used for this information.
5. This collection of information does not have a significant impact on small businesses or other entities.
6. If DFAS-CL does not receive the information, annuity payments are suspended. The requirement to complete the form ensures annuity eligibility and helps alleviate the opportunity for fraud and abuse of dependent benefits.
7. There are no special circumstances that would require this collection to be conducted in a manner inconsistent with 5 CFR 1320.5(d)(2).
8. The Federal Register notice for this collection of information was published on November 4, 2009 (74 FR 57153). No public comments were received.
No payment or gift will be provided to respondents, other than payments paid as entitlements
resulting from meeting eligibility requirements.
10. There is a Privacy Act Statement on the form. DFAS-CL certifies that the information collected is maintained in accordance with the Privacy Act of 1974, and OMB Circular A-130, Management of Federal Information Resources. Disclosure of the Social Security Number (SSN) is used for positive identification due to the payment of a benefit.
11. Questions of a sensitive nature such as those pertaining to sexual behavior and attitudes, or
religious beliefs are not asked. A brief description of the reason for medical incapacitation is required to determine eligibility for payment.
12. Estimation of Respondent Burden:
Number of Respondents 120
Responses per Respondent 1
Time Required per Response 2 hours
Total Burden Hour 240 hours
There are no additional costs, such as start-up or capital costs, to the respondents.
14. Estimated annualized cost associated with government review totals $ 286.80
Material:
Printing: 120 forms per year @ $0.15 = $18.00
Mailing: 120 forms per year @ $0.44 = $52.80
Labor & Overhead to Process Forms:
Based on hourly wage of $21.66
($21.66 x 12 minutes = $1.80 x 120 forms) = $216.00
$286.80
15. This is an extension of a previously approved collection.
The information collected will not be published or tabulated.
17. Approval is not sought to avoid display of the expiration date.
18. There are no exceptions to the certification statement identified in Item 19 of the OMB Form 83-I.
COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL METHODS.
Statistical methods are not employed in this collection of information.
| File Type | application/msword |
| File Title | Supporting Statement |
| Author | Bob Cushing |
| Last Modified By | Patricia L Toppings |
| File Modified | 2010-01-31 |
| File Created | 2006-05-25 |