Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form RI 20-126 Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84	Form and Instruction	Modified	Available
E8-5659.pdf	Supplementary Document	Uploaded 2019-06-07	Available
RI20-126_2015_02_MarkUp.pdf	Supplementary Document	Uploaded 2019-06-07	Available
RI20-126_2019_05_MarkUp.pdf	Supplementary Document	Uploaded 2019-06-07	Available
RI20-126_OMBSupportingStatement_2019_07_23.docx	Supporting Statement A	Uploaded 2019-07-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
218495	Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84	Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0268	ICR Reference No: 201905-3206-003
Status: Active	Previous ICR Reference No: 201510-3206-005
Agency/Subagency: OPM	Agency Tracking No: RI 20-126
Title: Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84
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: 10/24/2019
	Date Received in OIRA: 06/10/2019
Terms of Clearance: This collection is approved based on the revised materials provided by the Agency.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2022	36 Months From Approved
Responses	1,000	0	0
Time Burden (Hours)	500	0	0
Cost Burden (Dollars)	13,437	0	0

---

Abstract: RI 20-126 is used to certify that an employee performed certain service with the District of Columbia (DC) that qualifies under section 1905 of PL 111-84 for determining retirement eligibility. However, this service cannot be used in the computation of a retirement benefit.The revision date is needed for inventory control of previously obsolete forms. The Privacy Act Statement has been updated due to a generic systematic review by our Chief Privacy Officer.

---

Authorizing Statute(s): PL: Pub.L. 111 - 84 1905 Name of Law: Certification of Qualifying DC Service Under Public Law 111-84 Sec 1905
  

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 61174	11/28/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 18327	04/30/2019
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84	RI 20-126, RI 20-126	Certification of Qualifying DC Service Under Section 1905 of PL 111-84 ,   Certification of Qualifying District of Columbia Service Under Section 1905 of P.L. 111-84

---

ICR Summary of Burden

table that charts list 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	1,000	0	0	0	0	1,000
Annual Time Burden (Hours)	500	0	0	0	0	500
Annual Cost Burden (Dollars)	13,437	0	0	13,437	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: $5,550

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: 06/10/2019

---