Claim Form Justification 2016

SUPPORTING STATEMENT

Claim for Death Benefits

A. JUSTIFICATION

1. Necessity of Information: The Public Safety Officers’ Benefits (PSOB) Program (42 U.S.C. § 3796, et seq.) provides a one-time benefit of $339,881, adjusted in accordance with subsection (h) of the PSOB Death Benefits Regulations, to the eligible survivors of local, state, tribal and federal public safety officers whose deaths result from traumatic injuries sustained in the line of duty, or eligible heart attacks, strokes, and vascular ruptures. The Report of Public Safety Officer’=s Death form is completed by the employing agency. The Claim for Death Benefits form is completed by the claimant. Both forms, along with supporting documentation, are filed with the Bureau of Justice Assistance to assist in evaluating whether claims are eligible under the PSOB Program and, if so, determining the eligibility of spouses, children, PSOB designees, life insurance beneficiaries, parents, and adult children of deceased public safety officers for this benefit.

2. Purpose for Use: The Report of Public Safety Officer’s Death form allows the employer to certify that the decedent was a public safety officer, that his or her death did occur in the line of duty, and that certain eligibility considerations (misconduct, gross negligence, suicide, voluntary intoxication) were not disqualifying factors in the death. The Claim for Death Benefits lists the officer’s survivors and ensures that only eligible beneficiaries are considered for PSOB purposes. The information on these forms is not readily available from sources other than the employing agency/claimant.

3. Use of Information Technology: The PSOB Report of Public Safety Officer’s Death form (OJP FORM 3650/6) and Claim for Death Benefits form (OJP FORM 3650/5) are available for downloading from the Bureau of Justice Assistance website at;

https://www.psob.gov/files/death_rpt.pdf

https://www.psob.gov/files/death_claim.pdf

As of May 2006, the forms can also be completed electronically and sent directly to the PSOB Office through the online application process at https://www.psob.gov. Supporting documentation can be attached to the online application or submitted via mail or fax as indicated below. The same contact information can be used to receive and submit the PSOB application forms from and to the PSOB Office.

Office of Justice Programs, Bureau of Justice Assistance

Public Safety Officers’ Benefits Office

810 Seventh Street, NW

Washington, D.C., 20531

1-888-744-6513 Toll free

202-616-0314 Fax

4. Identification of Duplication: This is the only federal program providing this specific service. The Report of Public Safety Officer’s Death form is the only form that directly asks the employing agency the information needed to assist in identifying if the officer in question suffered a line-of-duty injury that caused his death. Similarly, the Claim for Death Benefits form is the only form that directly asks the claimant the information needed to identify survivors who may be eligible to receive the PSOB benefit. The information collection forms are also used for activities under the Federal Employees Compensation Act and the D.C. Retirement and Disability Act.

5. Impact on Small Businesses or Other Entities: The information collection requirements do not impact small businesses or other entities as described in the instructions for completing OMB Form 83-I.

6. Consequences if Collection is not Conducted: The PSOB Report of Public Safety Officer’s Death and Claim for Death Benefits forms only have to be completed once by the employing agency/claimant. Without the statutorily required information collected on these forms, BJA would not be able to confirm that the officers’ deaths were either from line-of-duty activities or eligible heart attacks, strokes, and vascular ruptures, and determinations could not be made with regard to which survivors are eligible for the PSOB benefits. In addition, BJA would not be able to authorize payments.

7. Special Circumstances: None.

8. Publication: The 60 and 30 day notices have been published in the federal register for public comments and no comments were received.

9. Payment to Respondents: The completion and successful processing of this application will entitle eligible beneficiary(ies) of a public safety officer who was killed or who died from eligible heart attacks, strokes, and vascular ruptures to receive a one-time death benefit of $339,881 (FY 2016). The Internal Revenue Service has ruled that this benefit is not subject to Federal income tax or federal estate tax.

10. Assurance of Confidentiality: All information on these forms is collected in accordance with the Privacy Act of 1974, as amended. All information that may identify individuals is safeguarded. Information relating to the circumstances and cause of the decedent’s death, however, is not protected by the Privacy Act. This information is available to organizations or persons conducting line-of-duty death research.

11. Questions of a Sensitive Nature: By their nature, questions addressing the circumstances of officers’ deaths, their family histories, their medical backgrounds, and information related to their employing public agencies are inherently sensitive. These inquiries must be made to determine if there are any disqualifying factors concerning an officer’s death and to confirm the eligibility of survivors under the PSOB Program.

12. Estimate of the Hour Burden: Annual Hour Burden for Claim for Death Benefits form

1. Number of Respondents: 350

2. Number of applications submitted per respondent: 1 application

3. Total annual applications: 350 x 1 = 350

4. Hours: 120 minutes

5. Total Annual Reporting Burden: 350 x 120 minutes per claim form = 42,000minutes / by 60 minutes per hour = 700 hours.

13. Estimate of the Total Annual Cost Burden: There is no capital or start up costs associated with information collection under this program. The cost to the respondents is the time (approximately 120 minutes) spent gathering the information and the transmission of the required form.

14. Estimates of Annualized Cost to the Federal Government: The assigned program manager for this program is paid at an annual rate of a GS-13/5 at $87,664 per year, plus $19,286 (or 22% in fringe benefits) = $ 106,950 / 52 weeks/40 hours per week equal an hourly rate of

$ 51.41. On average, each application review takes approximately 240 minutes 2 hrs x $51.41 = $ 102.82 per application x 350 applications = $ 28,275.50.

15. Program Changes or Adjustments: None. This is a request for a revision of a previously approved collection form, with approval expiring on May 31, 2007.

16. Publishing Information: The information collected will not be published.

17. Approval to not Displaying the OMB Approval: The present information collection request does not seek such an approval.

18. Certification for Paperwork Reduction Act Submission: See attached Certification Statement.

B. STATISTICAL METHODS

Statistical methods will not be used in this information collection.