Information Collection

Application for Survivor Death Benefits

IC 33838 under ICR 201207-3220-002 · OMB 3220-0031.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0031 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AA-21 (11-08) Application for Survivor Death Benefits	Form and Instruction
AA-21 (11-08) Application for Lump-Sum Death Payments and Annuities Un Form AA-21 (11-08).pdf	Form and Instruction
G-131 Authorization of Payment and Release of All Claims to a Form G-131 (06-06).pdf	Form and Instruction
AA-11a (09-03) Designation or Change of Beneficiary for Employees with Form AA-11a (09-03).pdf	Form and Instruction
AA-21CERT Application Summary and Certification Form AA-21cert (02-00) Example.pdf	Form
Form AA-21cert (02-00) All Possible.pdf AA-21, All Possible	IC Document

IC Title:

Application for Survivor Death Benefits

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 219 20 CFR 234 20 CFR 217

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	AA-21 (11-08)	Application for Lump-Sum Death Payments and Annuities Unpaid at Death	Form AA-21 (11-08).pdf	Yes	Yes	Paper Only
Form and Instruction	G-131	Authorization of Payment and Release of All Claims to a Death Benefit or Accrued Annuity Payment	Form G-131 (06-06).pdf	No		Paper Only
Form and Instruction	AA-11a (09-03)	Designation or Change of Beneficiary for Employees with Service Prior to January 1, 1975, for Residual Lump Sum	Form AA-11a (09-03).pdf	No		Paper Only
Form	AA-21CERT	Application Summary and Certification	Form AA-21cert (02-00) Example.pdf	Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

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

FR Citation: 75 FR 43727

Number of Respondents: 5,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 82 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,500	-1,000	6,500
Annual IC Time Burden (Hours)	1,767	-316	2,083
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
AA-21, All Possible	Form AA-21cert (02-00) All Possible.pdf	05/26/2009

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