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Claim for Death Benefits
Claim for Death Benefits
OMB: 1121-0024
IC ID: 12363
OMB.report
DOJ/OJP
OMB 1121-0024
ICR 201605-1121-001
IC 12363
( )
Documents and Forms
Document Name
Document Type
Form 3650/5
Claim for Death Benefits
Form
3650/5 Claim for Death Benefits
DEATH BENEFITS CLAIM FORM.pdf
www.psob.gov
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Claim for Death Benefits
Agency IC Tracking Number:
BJA
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
3650/5
Claim for Death Benefits
DEATH BENEFITS CLAIM FORM.pdf
www.psob.gov
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
Survivor Compensation
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
350
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
100 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
350
0
30
0
320
0
Annual IC Time Burden (Hours)
700
0
220
0
480
0
Annual IC Cost Burden (Dollars)
3,281
0
281
0
3,000
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.
