3220-0032

OMB NO. 3220-0032

Justification

Survivor Questionnaire

RRB Form RL-94-F

1. Circumstances of information collection - Under Section 6 of the Railroad Retirement Act (RRA), benefits that may be due on the death of a railroad employee or a survivor annuitant include (1) a lump-sum death benefit (2) a residual lump-sum payment (3) accrued annuities due but unpaid at death, and (4) monthly survivor insurance payments.

The requirements for determining the entitlement of possible beneficiaries to these benefits are prescribed in 20 CFR 234.

2. Purposes of collecting/consequences of not collecting the information - Form RL-94-F, Survivor Questionnaire, is used by a Railroad Retirement Board (RRB) field office after receiving notification of the death of a railroad employee or survivor annuitant, to obtain additional information needed to determine if benefits are payable under the RRA. This notification can be by means of a returned check, telephone call, or other sources such as the Social Security Administration (SSA), Veterans Affairs, or a funeral home. The information obtained by Form RL-94-F is used to determine:

• the railroad employee's insured status;

• beneficiaries eligible for survivor benefits; and

• beneficiaries of unpaid annuities and residual lump sums. Information relating to the employee's insured status is used to determine whether survivor applications should be filed with the RRB or SSA. The first page of Form RL-94-F serves as a transmittal letter and also contains instructions for the completion and return of the questionnaire to the RRB. The identifying information in Items 1-4 of the questionnaire is completed by the RRB field office before the form is released.

Form RL-94-F is completed in its entirety, or in part, depending on the following:

• In most cases there is no surviving widow(er) living with the deceased railroad employee at the time of death so the field office mails the form to the nearest surviving relative. If there is no known surviving relative, the field office mails the form to the last known address of the employee or survivor annuitant and addresses it to: “The Family or Friends of [the name of the deceased employee or survivor annuitant is inserted], Deceased. The form is completed by the respondent in its entirety (i.e., items 5-18).

• In other cases, there is a surviving widow(er), and only items 5-10 and 18 are completed.

• In still other cases, information already available from RRB records requires that only item 18 be completed.

After completing the form, it is returned to the RRB field office in the return envelope provided.

The RRB proposes the following non-burden impacting editorial and cosmetic changes to Form RL-94-F.

• Editorial changes to the first sentence of the transmittal to soften the introduction and clarify why the addressee has been sent the form.

• Expand the introductory paragraph of Section 3 to explain that if there is more than one executor, payer of burial expenses, etc., their name, address, and telephone number should be entered in Section 5, Remarks.

• Item 11 - Add a request for the telephone number of the Funeral Home.

• Item 14b - To take into consideration situations where the payer of the burial expenses uses estate funds and there is also a trust agreement in force, Item 14b has been divided into 14b.1 and 14b.2.

• Item 14b.1 - Add a reference to a trust agreement and instructions that if the payer is using funds from the employee’s trust agreement to complete new Item 14b.2.

• Item 14b.2 - Provide lines for the name, address, and daytime telephone number of the Trustee, with instructions that if there is more than one trustee, their name, address, and telephone number should be entered in Section 5, Remarks.

• Item 14c - Add an instruction by the “Yes” box to “Explain below,” and a “Go to Item 15” by the “No” box.

• Section 6 - Delete requests for both a work and home telephone number and add a request for a “Daytime” telephone number.

To our knowledge no other agency uses a form comparable to Form RL-94-F.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - Not practical because the RRB releases the RL-94F with pre-filled data.

4. Efforts to identify duplication - This information collection does not duplicate any other information collection.

5. Small business respondents - N.A.

6. Consequences of less frequent collection - Not applicable since the form is completed only once for each instance of an employee or survivor annuitant death.

7. Special circumstances - N.A.

8. Consultations outside the agency - In accordance with 5 CFR 320.8(d), comments were invited from the public regarding the information collection. The notice to the public was published on page 51833 of the August 27, 2012, Federal Register. No comments or requests for additional information were received.

9. Payments or gifts to Respondents - None

10. Confidentiality - Privacy Act System of Records RRB-22, Railroad Retirement, Survivor and Pensioner Benefit System. In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at http://www.rrb.gov/pdf/PIA/PIA-BPO.pdf.

11. Sensitive questions - N.A.

12. Estimate of respondent burden - The estimated burden for this collection is unchanged as follows:

Estimated Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
RL-94-F Items 5-10, and 18	50	9	8
RL-94-F, items 5-18	7,200	11	1,320
RL-94-F, item 18 only	750	5	63
Total	8,000		1,391

13. Estimate of annual cost to respondents or record keepers - N.A.

14. Estimate of cost to Federal Government - N.A.

15. Explanation for changes in burden - N.A

16. Time schedule for data collection and publication - The results of this collection will not be published.

17. Request not to display OMB expiration date - The RL-94-F is seldom revised. Given the costs associated with redrafting, reprinting, and distributing the form in order to keep the appropriate OMB expiration date in place, the RRB requests the authority to not display the expiration date on the form.

18. Exceptions to Certification Statement - None

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