Request for Payment of Federal Benefit by Check, EFT Waiver Form

Forms and Documents

Document Name	Status
Form FS Form 1201W-DFAS EFT Waiver Form - DFAS Form and Instruction	Unchanged
Form FS Form 1201W (SP) EFT Waiver Form Form and Instruction	Unchanged
Supporting Stmt_2018_1530-0019.doc Supporting Statement A	2018-10-19

IC Document Collections

IC ID	Document Title	Status
211679	EFT Waiver Form - DFAS Form and Instruction	Unchanged
202118	EFT Waiver Form Form and Instruction	Unchanged

ICR Details

OMB Control No: 1530-0019	ICR Reference No: 201810-1530-003
Status: Active	Previous ICR Reference No: 201507-1530-002
Agency/Subagency: TREAS/FISCAL	Agency Tracking No:
Title: Request for Payment of Federal Benefit by Check, EFT Waiver Form
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: 12/06/2018
	Date Received in OIRA: 10/30/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2021	36 Months From Approved	12/31/2018
Responses	3,250	0	3,250
Time Burden (Hours)	1,083	0	1,083
Cost Burden (Dollars)	1,593	0	1,593

---

Abstract: 31 CFR part 208 requires that all Federal non-tax payments be made by electronic funds transfer (EFT). This form is used to collect information from individuals requesting a waiver from the EFT requirement because of a mental impairment and/or who live in a remote geographic location that does not support the use of EFT. These individuals may continue to receive payment by check. However, 31 CFR part 208 requires individuals requesting one of these waiver conditions to submit a written justification.

---

Authorizing Statute(s): US Code: 31 USC 3332 Name of Law: Required Direct Deposit
  

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:
	83 FR 31034	07/02/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 54658	10/30/2018
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
EFT Waiver Form	FS Form 1201W (SP), FS Form 1201W	Solicitud Para Recibir Su Pago de Beneficios Federales En Cheque ,   Request for Payment of Federal Benefits by Check
EFT Waiver Form - DFAS	FS Form 1201W-DFAS	Request for Payment by Federal Benefits Check

---

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	3,250	3,250	0	0	0	0
Annual Time Burden (Hours)	1,083	1,083	0	0	0	0
Annual Cost Burden (Dollars)	1,593	1,593	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: $1,430

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: 10/30/2018

---