Health Benefits Election Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0160 can be found here:

Documents and Forms

Document Name Document Type
Form SF 2809 Health Benefits Election Form Form and Instruction
SF 2809 Health Benefits Election Form SF 2809 November 2014.pdf www.opm.gov/forms/pdf_fill/sf2809.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 890.301 through 890-307 5 CFR 890.805 through 809.807 5 CFR 890-1105 through 890.1110 (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	SF 2809	Health Benefits Election Form	SF 2809 November 2014.pdf	http://www.opm.gov/forms/pdf_fill/sf2809.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: 18,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	18,000	18,000
Annual IC Time Burden (Hours)	9,000	9,000
Annual IC Cost Burden (Dollars)	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.