Statement of Claimant or Other Person

Forms and Documents

Document Name	Status
Form G-93 (11-12) Statement of Claimant or Other Person Form	Modified
Form G-93 (11-12) Statement of Claimant or Other Person Form	Modified
3220-0183.doc Supporting Statement A	2015-10-09

IC Document Collections

IC ID	Document Title	Status
44220	Statement of Claimant or Other Person Form	Modified
189894	Statement of Claimant or Other Person Form	Modified

ICR Details

OMB Control No: 3220-0183	ICR Reference No: 201509-3220-002
Status: Historical Active	Previous ICR Reference No: 201208-3220-003
Agency/Subagency: RRB	Agency Tracking No:
Title: Statement of Claimant or Other Person
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: 03/30/2016
	Date Received in OIRA: 10/09/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	36 Months From Approved	03/31/2016
Responses	200	0	900
Time Burden (Hours)	50	0	225
Cost Burden (Dollars)	0	0	0

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Abstract: Under Section 2 of the Railroad Retirement Act and the Railroad Unemployment Insurance Act, pertinent information and proofs must be submitted by an applicant so that the Railroad Retirement Board can determine his or her entitlement to benefits. The collection obtains information supplementing or changing information previously provided by an applicant.

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Authorizing Statute(s): None

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:
	80 FR 36862	06/26/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 58526	09/29/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Statement of Claimant or Other Person	G-93 (11-12)	Statement of Claimant or Other Person
Statement of Claimant or Other Person	G-93 (11-12)	Statement of Claimant or Other Person

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ICR Summary 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	200	900	0	0	-700	0
Annual Time Burden (Hours)	50	225	0	0	-175	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: The annual responses for this collection have decreased by 700, from 900 to 200 and the burden hours have decreased by 175, from 225 to 50. This decrease in proposed burden is due to automation initiatives which allow the RRB to calculate the actual amount of responses received. We have shown the decrease in annual responses and burden hours as an adjustment.

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Annual Cost to Federal Government: $0

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? Yes

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: 10/09/2015

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