Information Collection

Benefits Package and Supporting Documentation

IC 208418 under ICR 201308-0915-005 · OMB 0915-0334.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0334 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Benefits Package and Supporting Documentation Form and Instruction
1 Certification of Status for Death Benefit - Alternative Certification of Status for Death Benefit - Alternative Calculation (Attachment 2).docx Form and Instruction
2 Certification of Status for Death Benefit - Standard Cal Certification of Status for Death Benefit - Standard Calculation (Attachment 1).docx Form and Instruction
3 Compensation Attachment 1 for Estate Compensation Attachment 1 for Estate.docx Form and Instruction
4 Compensation Attachment 1 for Reps Compensation Attachment 1 for Reps.docx Form and Instruction
5 Compensation Attachment 1 Compensation Attachment 1.pdf Form and Instruction
6 Death Benefit Certification of Relationship (Survivor At Death Benefit Certification of Relationship (Survivor Attach 3).docx Form and Instruction
7 Lost Employment Income Certification - Estate (attatchme Lost Employment Income Certification - Estate (attatchment 3).docx Form and Instruction
8 Lost Employment Income Certification (Attach 3) Lost Employment Income Certification (Attach 3).docx Form and Instruction
9 Unreimbursed Medical Expenses Certification - Estate (At Unreimbursed Medical Expenses Certification - Estate (Attachment 2).docx Form and Instruction
10 Unreimbursed Medical Expenses Certification (Attach 2) Unreimbursed Medical Expenses Certification (Attach 2).docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Benefits Package and Supporting Documentation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Certification of Status for Death Benefit - Alternative Calculation (Attachment 2)	Certification of Status for Death Benefit - Alternative Calculation (Attachment 2).docx	Yes	Yes	Paper Only
Form and Instruction	2	Certification of Status for Death Benefit - Standard Calculation (Attachment 1)	Certification of Status for Death Benefit - Standard Calculation (Attachment 1).docx	Yes	Yes	Paper Only
Form and Instruction	3	Compensation Attachment 1 for Estate	Compensation Attachment 1 for Estate.docx	Yes	Yes	Paper Only
Form and Instruction	4	Compensation Attachment 1 for Reps	Compensation Attachment 1 for Reps.docx	Yes	Yes	Paper Only
Form and Instruction	5	Compensation Attachment 1	Compensation Attachment 1.pdf	Yes	Yes	Paper Only
Form and Instruction	6	Death Benefit Certification of Relationship (Survivor Attach 3)	Death Benefit Certification of Relationship (Survivor Attach 3).docx	Yes	Yes	Paper Only
Form and Instruction	7	Lost Employment Income Certification - Estate (attatchment 3)	Lost Employment Income Certification - Estate (attatchment 3).docx	Yes	Yes	Paper Only
Form and Instruction	8	Lost Employment Income Certification (Attach 3)	Lost Employment Income Certification (Attach 3).docx	Yes	Yes	Paper Only
Form and Instruction	9	Unreimbursed Medical Expenses Certification - Estate (Attachment 2)	Unreimbursed Medical Expenses Certification - Estate (Attachment 2).docx	Yes	Yes	Paper Only
Form and Instruction	10	Unreimbursed Medical Expenses Certification (Attach 2)	Unreimbursed Medical Expenses Certification (Attach 2).docx	Yes	Yes	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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