Physician Certificate for Child Annuitant

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DD Form 2828 Physician Certificate for Child Annuitant	Form	Modified	Available
SORN 2009.pdf	Supplementary Document	Uploaded 2013-06-26	Available
DoD 7000.14-R.pdf	Supplementary Document	Uploaded 2013-06-26	Available
AUTHORITY_LINKS.doc	Supplementary Document	Uploaded 2013-06-26	Available
DD 2828 - Review.pdf	Supplementary Document	Uploaded 2013-06-26	Available
Supporting statement DD 2828 (0730-0011).doc	Supporting Statement A	Uploaded 2013-06-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
5643	Physician Certificate for Child Annuitant	Form	Modified

ICR Details

OMB Control No: 0730-0011	ICR Reference No: 201306-0730-001
Status: Historical Active	Previous ICR Reference No: 201001-0730-001
Agency/Subagency: DOD/DFAS	Agency Tracking No:
Title: Physician Certificate for Child Annuitant
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/13/2013
	Date Received in OIRA: 06/26/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2016	36 Months From Approved	08/31/2013
Responses	120	0	120
Time Burden (Hours)	240	0	240
Cost Burden (Dollars)	0	0	0

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Abstract: The DD 2828 is required and must be on file to support an incapacitation occuring prior to age 18. The form provides the authority for the Directorate of Retired and Annuitant Pay, Defense Finance and Accounting Service - Cleveland (DFAS-CL/PD) to establish and pay a Retired Service Member's Family Protection Plan (RSFPP) or Survivor Benefit Plan (SBP) annuity to the incapacitated individual. The form is completed by the child annuitant, and/or their guardian, custodian or legal representative and certified by the physician.

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Authorizing Statute(s): US Code: 10 USC 1435 Name of Law: null
   US Code: 10 USC 1447 Name of Law: null
   EO: EO 9397 Name/Subject of EO: null
   US Code: 10 USC 1401 Name of Law: null
  

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:
	78 FR 20095	04/03/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 20095	04/03/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Physician Certificate for Child Annuitant	DD Form 2828	Physician Certificate for Child Annuitant

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ICR Summary of Burden

table that charts list 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	120	120	0	0	0	0
Annual Time Burden (Hours)	240	240	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: $304

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: 06/26/2013

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