RI 94-7, Death Benefit Payment Rollover Election Form

Forms and Documents

Document	Type	Status	Availability
Form RI 94-7 RI 94-7, Death Benefit Payment Rollover Election Form	Form and Instruction	Unchanged	Repair queued
RI94-007_30DayFRN_Published_2017_05_05.pdf	Supplementary Document	Uploaded 2017-05-12	Available
RI94-007_OMB_Support_Stmt_2017_04_11.doc	Supporting Statement A	Uploaded 2017-05-12	Repair queued
RI94-007_60dayFRN_Published_2016_07_11.pdf	Supplementary Document	Uploaded 2017-03-31	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
33723	RI 94-7, Death Benefit Payment Rollover Election Form	Form and Instruction	Unchanged

ICR Details

OMB Control No: 3206-0218	ICR Reference No: 201703-3206-018
Status: Historical Active	Previous ICR Reference No: 201401-3206-002
Agency/Subagency: OPM	Agency Tracking No:
Title: RI 94-7, Death Benefit Payment Rollover Election Form
Type of Information Collection: Reinstatement without change of a previously 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: 05/15/2017
Terms of Clearance: This collection should be reported in the Information Collection Budget. When it is next submitted for renewal, please include the most recent SORN and PIA.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2020	36 Months From Approved
Responses	3,444	0	0
Time Burden (Hours)	3,444	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Provides FERS surviving spouses and surviving former spouses with the means to elect payment of FERS rollover-eligible benefits directly or to an Individual Retirement Arrangement (IRA), eligible employer plan or Thrift Savings Plan (TSP) account.

---

Authorizing Statute(s): PL: Pub.L. 102 - 318 106 Name of Law: Unemployment Compensation Amendment of 1992
  

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 44898	07/11/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 21276	05/05/2017
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 94-7, Death Benefit Payment Rollover Election Form	RI 94-7	Death Benefit Payment Rollover Election

---

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	3,444	0	0	0	0	3,444
Annual Time Burden (Hours)	3,444	0	0	0	0	3,444
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: $155,021

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: 05/15/2017

---