Information Collection

Claim for Death Benefits

IC 12363 under ICR 201605-1121-001 · OMB 1121-0024.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3650/5 Claim for Death Benefits Claim for Death Benefits	Form
3650/5 Claim for Death Benefits DEATH BENEFITS CLAIM FORM.pdf	Form

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3650/5			www.psob.gov	Yes	Yes	Fillable Fileable

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	350	30	320
Annual IC Time Burden (Hours)	700	220	480
Annual IC Cost Burden (Dollars)	3,281	281	3,000

Documents for IC

table that charts IC Documents
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.

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