Life Insurance Election

Forms and Documents

Document Name	Status
Form SF 2817 Life Insurance Election Form and Instruction	Modified
FACES 2017 FINAL 12212017signed.pdf Supplementary Document	2018-03-12
ARS PIA Final 12212017signed.pdf Supplementary Document	2018-03-12
Citations for SF 2817.pdf Supplementary Document	2018-03-12
SF2817_30dayFRN_Published_2018_03_12.pdf Supplementary Document	2018-03-12
SF2817_Published_60DayFRN_2017_05_26.pdf Supplementary Document	2018-03-12
SF2817_OMBSupportingStmt_2018_05_30.docx Supporting Statement A	2018-05-30

IC Document Collections

IC ID	Document Title	Status
33739	Life Insurance Election Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0230	ICR Reference No: 201803-3206-002
Status: Active	Previous ICR Reference No: 201408-3206-005
Agency/Subagency: OPM	Agency Tracking No: SF 2817
Title: Life Insurance Election
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/04/2018
	Date Received in OIRA: 03/14/2018
Terms of Clearance: This collection is approved based on the revised materials provided by the Agency. Before this collection is next submitted to OMB, OPM should consider making it a common form as it is an information collection used government-wide for the same purpose.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2021	36 Months From Approved
Responses	150	0	0
Time Burden (Hours)	38	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Standard Form 2817, Life Insurance Election, is used by Federal employees and assignees (those who have acquired control of an employee/annuitant's coverage through an assignment or ''transfer'' of the ownership of the life insurance).

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Authorizing Statute(s): US Code: 5 USC Chapter 87 Name of Law: Life Insurance
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 24404	05/26/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 1075	03/12/2018
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Life Insurance Election	SF 2817, SF 2817	Life Insurance Election ,   Life Insurance Election

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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	150	0	0	0	0	150
Annual Time Burden (Hours)	38	0	0	0	0	38
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:

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Annual Cost to Federal Government: $0

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

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Common Form ICR:  No

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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: 03/14/2018

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