Report of Withholdings and Contributions for Health Benefits, Life Insurance and Retirement

Forms and Documents

Document Name	Status
Form OPM 1523 OPM 1523 Form and Instruction	Modified
Form SF 2812A SF 2812A Form and Instruction	Modified
Form SF2812 SF 2812 Form and Instruction	Modified
Supporting Stmt FERS-3206-0262.doc Supporting Statement A	2018-10-25
30 Day Notice 2018-21918 50975 0262.pdf Supplementary Document	2018-10-17
60 Day Notice 7505 2018-03439 0262.pdf Supplementary Document	2018-10-17

IC Document Collections

IC ID	Document Title	Status
209211	OPM 1523 Form and Instruction	Modified
209210	SF 2812A Form and Instruction	Modified
209209	SF 2812 Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0262	ICR Reference No: 201810-3206-002
Status: Active	Previous ICR Reference No: 201305-3206-001
Agency/Subagency: OPM	Agency Tracking No:
Title: Report of Withholdings and Contributions for Health Benefits, Life Insurance and Retirement
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: 11/19/2018
	Date Received in OIRA: 10/19/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2021	36 Months From Approved
Responses	5,400	0	0
Time Burden (Hours)	2,700	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Abstract: Public Law 112-96, Section 5001, the "Middle Class Tax Relief and Job Creation Act of 2012," requires OPM to collect information. OPM collects this information via the following forms: 1) Report of Withholdings and Contributions for Health Benefits, Life Insurance and Retirement (Standard Form 2812); 2) Report of Withholdings and Contributions for Health Benefits By Enrollment Code (Standard Form 2812-A); 3) Supplemental Semiannual Headcount Report (OPM Form 1523). The current Standard Form 2812, Standard Form 2812-A, and OPM Form 1523 reflect that there is no change in the law.

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Authorizing Statute(s): PL: Pub.L. 112 - 96 5001 Name of Law: Middle Class Tax Relief and Job Creation Act of 2012
   US Code: 5 USC 83, 84, 87, 89 Name of Law: null
  

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:
	83 FR 7504	02/21/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 50975	10/10/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
SF 2812	SF2812	Report of Withholdings and Contributions for Health Benefits,Life Insurance and Retirement
SF 2812A	SF 2812A	Report of Withholdings and Contributions for Health Benefits by Enrollment Code
OPM 1523	OPM 1523	Supplemental Semiannual Headcount Report

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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	5,400	0	0	0	0	5,400
Annual Time Burden (Hours)	2,700	0	0	0	0	2,700
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: $75,600

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.     No

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: 10/19/2018

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