Health Benefits Election Form

OPM 2809, Health Benefits Election Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0141 can be found here:

Documents and Forms

Document Name Document Type
Form OPM 2809 Health Benefits Election Form Form and Instruction
OPM 2809 Health Benefits Election Form OPM 2809 July 2013.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Health Benefits Election Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR Ch. 1, Part 890.301 thru 307 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OPM 2809	Health Benefits Election Form	OPM 2809 July 2013.pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title: OPM/Central-1	FR Citation: 73 FR 15013

Number of Respondents: 30,000	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	Previously Approved
Annual Number of Responses for this IC	30,000	0	30,000
Annual IC Time Burden (Hours)	11,667	-5,000	16,667
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.