RI 20-123, Request for Case Review for Enhanced Disability Annuity Benefit

Forms and Documents

Document Name	Status
Form RI 20-123 RI 20-123, Request for Case Review for Enhanced Disability Annuity Benefit Form and Instruction	Modified
RI 20-123 FRN Published 2017-04136.pdf Supplementary Document	2017-03-22
RI20-123_60DayFRN_Published_2016_06_22.pdf Supplementary Document	2017-03-22
RI 20-123_ SS_ Request for Case Review for Enhanced Disability Annuity Benefit 09_2016.doc Supporting Statement A	2017-03-22

IC Document Collections

IC ID	Document Title	Status
194854	RI 20-123, Request for Case Review for Enhanced Disability Annuity Benefit Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0254	ICR Reference No: 201703-3206-004
Status: Historical Active	Previous ICR Reference No: 201401-3206-004
Agency/Subagency: OPM	Agency Tracking No:
Title: RI 20-123, Request for Case Review for Enhanced Disability Annuity Benefit
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/02/2017
	Date Received in OIRA: 03/30/2017
Terms of Clearance: OPM must re-submit this form with a privacy act statement and provide the updated SORN and PIA upon renewal.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2019	36 Months From Approved	09/30/2017
Responses	100	0	100
Time Burden (Hours)	8	0	8
Cost Burden (Dollars)	0	0	0

---

Abstract: Form RI 20-123, Request for Case Review for Enhanced Disability Annuity Benefit is available only on the OPM web site. It is used by retirees separated for disability and the survivors of retirees separated for disability to request that Retirement Operations review the computations of disability annuities to include the formulae provided in law for individuals who performed service as law enforcement officers, firefighters, nuclear materials carriers, air traffic controllers, Congressional employees, and Capitol and Supreme Court police.

---

Authorizing Statute(s): US Code: 5 USC 8337 Name of Law: Disability Retirement (CSRS)
   US Code: 5 USC 8339 Name of Law: Computation of Annuity (CSRS)
   US Code: 5 USC 8452 Name of Law: Computation of disability annuity (FERS)
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 40731	06/22/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 12475	03/03/2017
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
RI 20-123, Request for Case Review for Enhanced Disability Annuity Benefit	RI 20-123	Request for Case Review for Enhanced Disability Annuity Benefit

---

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	100	100	0	0	0	0
Annual Time Burden (Hours)	8	8	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $5,550

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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

---

Common Form ICR:  No

---

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: 03/30/2017

---