SF 2800, Application for Death Benefits Under the Civil Service Retirement System/SF 2800A, Documentation and Elections in Support of Application for Death Benefits When Deceased Was an Employee

Forms and Documents

Document Name	Status
Form SF 2800 Application for Death Benefits Under the Civil Service Retirement System Form and Instruction	Modified
SF 2800-1 (07-11).pdf Supplementary Document	2012-01-04
SF 2800A (Dec 2008) Mark Up.pdf Supplementary Document	2012-01-04
SF 2800A March 2012 Markup.pdf Supplementary Document	2012-01-04
30-day FRN.pdf Supplementary Document	2012-01-04
60-day FRN.pdf Supplementary Document	2012-01-04
JUSTIFICATION TO OMB FOR SF 2800.doc Justification for No Material/Nonsubstantive Change	2011-06-21
SF 2800 Supporting Statement.doc Supporting Statement A	2012-01-04

IC Document Collections

IC ID	Document Title	Status
33627	Application for Death Benefits Under the Civil Service Retirement System Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0156	ICR Reference No: 201201-3206-006
Status: Historical Active	Previous ICR Reference No: 201106-3206-008
Agency/Subagency: OPM	Agency Tracking No:
Title: SF 2800, Application for Death Benefits Under the Civil Service Retirement System/SF 2800A, Documentation and Elections in Support of Application for Death Benefits When Deceased Was an Employee
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/26/2012
	Date Received in OIRA: 01/26/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2015	36 Months From Approved	06/30/2012
Responses	74,800	0	74,800
Time Burden (Hours)	56,100	0	56,100
Cost Burden (Dollars)	0	0	0

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Abstract: SF 2800 is needed to collect information so that OPM can pay death benefits to the survivors of Federal employees and annuitants. SF 2800A is needed for deaths in service so that survivors can make the needed election regarding military service. Every applicant who uses SF 2800 should read SF 2800-1, Applying for Death Benefits under CSRS. This brief booklet provides the general information applicants need to understand what they are applying for. SF 2800 was approved by OMB as a nomaterial or nonsubstantial change on 09/30/2011. SF 2800A was revised to bring the form up-to-date.

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Authorizing Statute(s): US Code: 5 USC Chapter 83, Section 8341 Name of Law: Survivor Annuities
   US Code: 5 USC Chapter 83, Section 8342 Name of Law: Lump-sum benefits; designation of beneficiary; order
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 39926	07/07/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 82002	12/29/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Application for Death Benefits Under the Civil Service Retirement System	SF 2800, SF 2800A	Application for Death Benefits, Civil Service Retirement System ,   Documentation and Elections in Support of Application for Death Benefits When Deceased Was an Employee at the Time of Death

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	74,800	74,800	0	0	0	0
Annual Time Burden (Hours)	56,100	56,100	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,325,300

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/26/2012

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