Information Collection

Benefits Package and Supporting Documentation

IC 208418 under ICR 201609-0915-001 · OMB 0915-0334.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0334 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Compensation Attachment 1.docx	Instruction
Compensation Attachment 1 for Reps.docx	Instruction
Compensation Attachment 1 for Estate.docx	Instruction
1.2 Unreimbursed Medical Expenses Certification (Attach 2) Unreimbursed Medical Expenses Certification (Attach 2).docx	Form
1.3 Lost Employment Income Certification (Attach 3).docx Lost Employment Income Certification (Attach 3).docx	Form
3.2 Certification of Status for Death Benefit - Alternative Certification of Status for Death Benefit - Alternative Calculation (Attachment 2).docx	Form
3.3 Lost Employment Income Certification - Estate (attatchme Lost Employment Income Certification - Estate (attatchment 3).docx	Form
3.4 Unreimbursed Medical Expenses Certification - Estate (At Unreimbursed Medical Expenses Certification - Estate (Attachment 4).docx	Form
4.1 Certification of Status for Death Benefit - Standard Cal Certification of Status for Death Benefit - Standard Calculation (Attachment 1).docx	Form
4.2 Death Benefit Certification of Relationship (Survivor At Death Benefit Certification of Relationship (Survivor Attach 2).docx	Form

IC Title:

Benefits Package and Supporting Documentation

Agency IC Tracking Number:

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Compensation Attachment 1.docx	Yes	No	Paper Only
Form	1.2	Unreimbursed Medical Expenses Certification (Attach 2)	Unreimbursed Medical Expenses Certification (Attach 2).docx	Yes	No	Paper Only
Form	1.3	Lost Employment Income Certification (Attach 3).docx	Lost Employment Income Certification (Attach 3).docx	Yes	No	Paper Only
Instruction			Compensation Attachment 1 for Reps.docx	Yes	No	Paper Only
Instruction			Compensation Attachment 1 for Estate.docx	Yes	No	Paper Only
Form	3.2	Certification of Status for Death Benefit - Alternative Calculation (Attachment 2)	Certification of Status for Death Benefit - Alternative Calculation (Attachment 2).docx	Yes	No	Paper Only
Form	3.3	Lost Employment Income Certification - Estate (attatchment 3)	Lost Employment Income Certification - Estate (attatchment 3).docx	Yes	No	Paper Only
Form	3.4	Unreimbursed Medical Expenses Certification - Estate (Attachment 4)	Unreimbursed Medical Expenses Certification - Estate (Attachment 4).docx	Yes	No	Paper Only
Form	4.1	Certification of Status for Death Benefit - Standard Calculation (Attachment 1)	Certification of Status for Death Benefit - Standard Calculation (Attachment 1).docx	Yes	No	Paper Only
Form	4.2	Death Benefit Certification of Relationship (Survivor Attach 2).docx	Death Benefit Certification of Relationship (Survivor Attach 2).docx	Yes	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	4	4
Annual IC Cost Burden (Dollars)	0	0

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.