Information Collection

Application for Survivor Insurance Annuities

IC 33834 under ICR 201601-3220-001 · OMB 3220-0030.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0030 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AA-17b (10-07) Application for Survivor Insurance Annuities	Form and Instruction
AA-17b (10-07) Application for Determination of Widow(ers) Disability Form AA-17b (10-07).pdf	Form and Instruction
AA-19a (10-07) Application for Determination of Child's Disability Form AA-19a (10-07).pdf	Form and Instruction
AA-17cert (09-15)( Application Summary and Certification Form AA-17cert (09-15) (All Possible).pdf	Form
AA-17cert (09-15) Application Summary and Certification Form AA-17cert (09-15) (Completed).pdf	Form
AA-17sum (09-15) ( Application Summary Form AA-17sum (09-15) (All Possible).pdf	Form
AA-17sum (09-15) ( Application Summary Form AA-17sum (09-15) (Completed).pdf	Form
RB-3 (11-08).pdf RB-3 Booklet; Furnishing Evidence to Support Your Claim	IC Document
Form RB-17 (09-15).pdf RB-17 Booklet, Survivor Annuities	IC Document
RB-17b (03-09).pdf RB-17b Booklet; Widow(ers) Disability Benefits	IC Document
RB-19a (5-99).pdf RB-19A Booklet; Child's Disability Benefits	IC Document
Form AA-17rec (11-14).pdf AA-17rec; Receipt for Claim	IC Document
Form RL-1S (04-07).pdf Transmittal Letter for self-administered retirement applications	IC Document
Form AA-17 (07-15).pdf AA-17, Application for Widow(ers) Annuity	IC Document
Form AA-18 (07-15).pdf AA-18, Application for Mother's/Father's and Child's Annuity	IC Document
Form AA-19 (07-15).pdf AA-19, Application for Child's Annuity	IC Document
Form AA-20 (07-15).pdf AA-20, Application for Parent's annuity	IC Document
Form AA-17 proposed.pdf AA-17, Proposed (less than 10 responses)	IC Document
Form AA-18 proposed.pdf AA-18 proposed (less than 10 responses)	IC Document
Form AA-19 proposed.pdf AA-19 proposed (less than 10 responses)	IC Document
Form AA-20 proposed.pdf AA-20 proposed (less than 10 responses)	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Application for Survivor Insurance Annuities

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 219 20 CFR 217 20 CFR 218 20 CFR 216

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	AA-17b (10-07)	Application for Determination of Widow(ers) Disability	Form AA-17b (10-07).pdf	No		Paper Only
Form and Instruction	AA-19a (10-07)	Application for Determination of Child's Disability	Form AA-19a (10-07).pdf	No		Paper Only
Form	AA-17cert (09-15)(all possible)	Application Summary and Certification	Form AA-17cert (09-15) (All Possible).pdf	Yes	Yes	Printable Only
Form	AA-17cert (09-15)	Application Summary and Certification	Form AA-17cert (09-15) (Completed).pdf	Yes	Yes	Printable Only
Form	AA-17sum (09-15) (All possible)	Application Summary	Form AA-17sum (09-15) (All Possible).pdf	Yes	Yes	Printable Only
Form	AA-17sum (09-15) (Completed)	Application Summary	Form AA-17sum (09-15) (Completed).pdf	Yes	Yes	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System

FR Citation: 79 FR 58874

Number of Respondents: 3,485

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 86 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,485	-237	3,722
Annual IC Time Burden (Hours)	1,315	-179	1,494
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
RB-3 Booklet; Furnishing Evidence to Support Your Claim	RB-3 (11-08).pdf	07/16/2009
RB-17 Booklet, Survivor Annuities	Form RB-17 (09-15).pdf	02/09/2016
RB-17b Booklet; Widow(ers) Disability Benefits	RB-17b (03-09).pdf	07/16/2009
RB-19A Booklet; Child's Disability Benefits	RB-19a (5-99).pdf	05/03/1999
AA-17rec; Receipt for Claim	Form AA-17rec (11-14).pdf	01/06/2016
Transmittal Letter for self-administered retirement applications	Form RL-1S (04-07).pdf	11/29/2012
AA-17, Application for Widow(ers) Annuity	Form AA-17 (07-15).pdf	02/26/2016
AA-18, Application for Mother's/Father's and Child's Annuity	Form AA-18 (07-15).pdf	02/26/2016
AA-19, Application for Child's Annuity	Form AA-19 (07-15).pdf	02/26/2016
AA-20, Application for Parent's annuity	Form AA-20 (07-15).pdf	02/26/2016
AA-17, Proposed (less than 10 responses)	Form AA-17 proposed.pdf	02/26/2016
AA-18 proposed (less than 10 responses)	Form AA-18 proposed.pdf	02/26/2016
AA-19 proposed (less than 10 responses)	Form AA-19 proposed.pdf	02/26/2016
AA-20 proposed (less than 10 responses)	Form AA-20 proposed.pdf	02/26/2016

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