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)

ICR 201909-3206-001

OMB: 3206-0172

Federal Form Document

ICR Details
3206-0172 201909-3206-001
Active 201509-3206-001
OPM SF 3104/SF 3104B
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)
Revision of a currently approved collection   No
Regular
Approved with change 11/15/2019
Retrieve Notice of Action (NOA) 09/03/2019
This collection is approved based on the revised materials provided by the Agency.
  Inventory as of this Action Requested Previously Approved
11/30/2022 36 Months From Approved 11/30/2019
16,751 0 16,751
16,751 0 16,751
225,066 0 0

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.

US Code: 5 USC Chapter 84 Name of Law: Federal Employees Retirement System
  
None

Not associated with rulemaking

  83 FR 61176 11/28/2018
84 FR 40440 08/14/2019
No

  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
No
No

$332,675
No
    Yes
    Yes
No
No
No
Uncollected
Charles Conyers 202 606-0125 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
09/03/2019


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