Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death

Forms and Documents

Document Name	Status
Form SF 3104B Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death Form and Instruction	Modified
Justification_SF3104B.doc Justification for No Material/Nonsubstantive Change	2012-01-09
SF3104B_November2010_Markup.pdf Supplementary Document	2012-01-09
SF3104B_April2012_MarkUp.pdf Supplementary Document	2012-01-09
SF 3104 SS.doc Supporting Statement A	2010-06-22

IC Document Collections

IC ID	Document Title	Status
33651	Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0172	ICR Reference No: 201201-3206-010
Status: Historical Active	Previous ICR Reference No: 201006-3206-004
Agency/Subagency: OPM	Agency Tracking No:
Title: Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/27/2012
	Date Received in OIRA: 01/26/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2013	09/30/2013	09/30/2013
Responses	16,751	0	16,751
Time Burden (Hours)	16,751	0	16,751
Cost Burden (Dollars)	0	0	0

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Abstract: SF 3104B, Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death, is used by applicants for death benefits under FERS if the deceased was a Federal employee at the time of death. We have made several editorial changes to the SF 3104B including but not restricted to: Basic Employee Death Benefit rates, Roth IRA, and etc. SF 3104B has been revised to inform applicants of these changes.

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Authorizing Statute(s): US Code: 5 USC Chapter 84 Name of Law: Federal Employees Retirement System
  

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:
	74 FR 67255	12/18/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 35091	06/21/2010
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 (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death	SF 3104B	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	16,751	16,751	0	0	0	0
Annual Time Burden (Hours)	16,751	16,751	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: $332,675

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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