Information Collection

Survey of Benefit Determination Letter and Statement

IC 228725 under ICR 201705-1212-003 · OMB 1212-0066.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1212-0066 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Email to Participants for LR Nelson Plan Final.docx	Instruction
Questionnaire for LR Nelson Participants Final.docx	Other-Survey
Template for Generic Clearance Submission for Survey 2017 Final.docx Template for Generic Clearance Submission for Survey	IC Document

IC Title:

Survey of Benefit Determination Letter and Statement

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

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
Instruction			Email to Participants for LR Nelson Plan Final.docx		Yes	No	Printable Only
Other-Survey			Questionnaire for LR Nelson Participants Final.docx		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 39

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
Annual Number of Responses for this IC	39	39
Annual IC Time Burden (Hours)	3	3
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Template for Generic Clearance Submission for Survey	Template for Generic Clearance Submission for Survey 2017 Final.docx	10/19/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.