Information Collection

Notice of Death and Statement of Compensation

IC 45663 under ICR 201301-3220-002 · OMB 3220-0005.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0005 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AA-12 (10-10) Notice of Death and Statement of Compensation	Form
AA-12 (10-10) Notice of Death and Request for Service Needed for Eligi AA-12 v2 (10-10).pdf www.rrb.gov/pdf/aa.12.pdf	Form

IC Title:

Notice of Death and Statement of Compensation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 209.6

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	AA-12 (10-10)	Notice of Death and Request for Service Needed for Eligibility	AA-12 v2 (10-10).pdf	http://www.rrb.gov/pdf/aa.12.pdf	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

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

FR Citation: 75 FR 43727

Number of Respondents: 579

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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