Information Collection

Qualified Domestic Relations Orders submitted to the PBGC

IC 43802 under ICR 201510-1212-002 · OMB 1212-0054.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1212-0054 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
PBGC QDRO BOOKLET 2015 Final.docx	Instruction
Supporting Statement 2015 Final.docx Supporting Statement 2015	IC Document

IC Title:

Qualified Domestic Relations Orders submitted to the PBGC

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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
Instruction			PBGC QDRO BOOKLET 2015 Final.docx		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,170

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,170	-191	1,361
Annual IC Time Burden (Hours)	2,117	-2,021	4,138
Annual IC Cost Burden (Dollars)	704,500	-165,900	870,400

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement 2015	Supporting Statement 2015 Final.docx	10/26/2015

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