Information Collection

Report of Public Safety Officers' Permanent and Total Disability

IC 12434 under ICR 201004-1121-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 1121-0166_PSOB DISABILITY FORM.doc 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	1121-0166_PSOB DISABILITY FORM.doc	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: 100

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	100	25	75
Annual IC Time Burden (Hours)	200	12	188
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.