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 (FERS)

ICR 201208-3206-003

OMB: 3206-0172

Federal Form Document

ICR Details
3206-0172 201208-3206-003
Historical Active 201201-3206-010
OPM
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 (FERS)
Revision of a currently approved collection   No
Regular
Approved without change 09/28/2012
Retrieve Notice of Action (NOA) 08/27/2012
  Inventory as of this Action Requested Previously Approved
09/30/2015 36 Months From Approved 09/30/2013
16,751 0 16,751
16,751 0 16,751
0 0 0

SF 3104, Application for Death Benefits (FERS), is used by persons applying for death benefits which may be payable under FERS because of the death of an employee, former employee, or retiree who was covered by FERS at the time of his/her death or separation from Federal Service. 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. Note: The SF 3104 has been revised to bring the form up-to-date. The following revisions are highlighted in the document: • Section I (Payment Instructions) – Instructions and Application form updated to reflect new Direct Deposit regulations. Applicants for recurring monthly benefits must now receive their payment by direct deposit or Direct Express debit card, unless their permanent payment address is outside the United States in a country where these programs are not available. • Added a field for the applicant's email address. • Clarified the language in Section H instructions regarding the crediting of National Guard duty. • Various language changes in the instructions.

US Code: 5 USC Chapter 84 Name of Law: Federal Employees Retirement System
  
None

Not associated with rulemaking

  77 FR 16567 03/21/2012
77 FR 49028 08/15/2012
No

  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
No
No

$332,675
No
No
No
No
No
Uncollected
Miles Windsor 202 606-8358 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/27/2012


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