Claim for Death Benefits

Forms and Documents

Document Name	Status
Form 3650/5 Claim for Death Benefits Form	Modified
CLAIM FORM JUSTIFICATION 2016.doc Supporting Statement A	2016-05-19

IC Document Collections

IC ID	Document Title	Status
12363	Claim for Death Benefits Form	Modified

ICR Details

OMB Control No: 1121-0024	ICR Reference No: 201605-1121-001
Status: Historical Active	Previous ICR Reference No: 200404-1121-001
Agency/Subagency: DOJ/OJP	Agency Tracking No: BJA
Title: Claim for Death Benefits
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/18/2016
	Date Received in OIRA: 05/25/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2019	36 Months From Approved
Responses	350	0	0
Time Burden (Hours)	700	0	0
Cost Burden (Dollars)	3,281	0	0

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Abstract: The Public Safety Officers Benefits (PSOB) Program provides a one-time benefit of $250,000 to the eligible survivors of local, state and federal public safety officers whose deaths result from traumatic injuries substained in the line of duty. The agency requires the information requested on this form to identify survivors and determine their eligibility for the Public Safety Officer Death Benefit in accordance with the statutory requirements found in 42 USC Sec. 3796. Respondents include surviving spouses, children and/or parents of deceased public safety officers.

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Authorizing Statute(s): US Code: 42 USC 3796 Name of Law: The Public Safety Officers Benefits
  

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:
	81 FR 1224	01/11/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 19240	04/04/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Claim for Death Benefits	3650/5	Claim for Death Benefits

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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	350	0	0	30	0	320
Annual Time Burden (Hours)	700	0	0	220	0	480
Annual Cost Burden (Dollars)	3,281	0	0	281	0	3,000

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The number of respondents increased slightly.

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Annual Cost to Federal Government: $28,275

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? No

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: 05/25/2016

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