Application for Death Benefits (FERS)/Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death (FERS)

Forms and Documents

Document Name	Status
Form Standard Form 3104 Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death Form and Instruction	Modified
FACES 2017 FINAL 12212017signed.pdf Supplementary Document	2019-09-03
ARS PIA Final 12212017signed.pdf Supplementary Document	2019-09-03
SF3104_2019_05_30DayFRNPublished_2019_08_14.pdf Supplementary Document	2019-09-03
SF3104_60DayFRN_Published_2018_11_28.pdf Supplementary Document	2019-09-03
SF3104_OMB_Supporting_Stmt_2019_10_30.docx Supporting Statement A	2019-10-30

IC Document Collections

IC ID	Document Title	Status
33651	Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0172	ICR Reference No: 201909-3206-001
Status: Active	Previous ICR Reference No: 201509-3206-001
Agency/Subagency: OPM	Agency Tracking No: SF 3104/SF 3104B
Title: Application for Death Benefits (FERS)/Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death (FERS)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/15/2019
	Date Received in OIRA: 09/03/2019
Terms of Clearance: This collection is approved based on the revised materials provided by the Agency.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2022	36 Months From Approved	11/30/2019
Responses	16,751	0	16,751
Time Burden (Hours)	16,751	0	16,751
Cost Burden (Dollars)	225,066	0	0

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Abstract: SF 3104, Application for Death Benefits (FERS), is used by persons applying for death benefits which may be payable under FERS because of the death of an employee, former employee, or retiree who was covered by FERS at the time of his/her death or separation from Federal Service. SF 3104B, Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death, is used by applicants for death benefits under FERS if the deceased was a Federal employee at the time of death.

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Authorizing Statute(s): US Code: 5 USC Chapter 84 Name of Law: Federal Employees Retirement System
  

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 61176	11/28/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 40440	08/14/2019
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
Application for Death Benefits (FERS); Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death	Standard Form 3104, Standard Form 3104 (Highlight w/Changes), Standard Form 3104B, Standard Form 3104B (Highlight w/Changes)	Application for Death Benefits: FERS ,   Application for Death Benefits (FERS) ,   Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death (FERS) ,   Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death (FERS)

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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	16,751	16,751	0	0	0	0
Annual Time Burden (Hours)	16,751	16,751	0	0	0	0
Annual Cost Burden (Dollars)	225,066	0	0	225,066	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: $332,675

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: 09/03/2019

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