Information Collection

Physician Certificate for Child Annuitant

IC 5643 under ICR 202004-0730-004 · OMB 0730-0011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0730-0011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Request form.doc	Other-Request form
DD 2828 Physician Certificate for Child Annuitant DD2828 20170403 old address.PDF www.dtic.mil/whs/directives/forms/index.htm	Form

IC Title:

Physician Certificate for Child Annuitant

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Request form			Request form.doc		No		Paper Only
Form	DD 2828	Physician Certificate for Child Annuitant	DD2828 20170403 old address.PDF	http://www.dtic.mil/whs/directives/forms/index.htm	Yes	No	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title: Defense Military Retiree and Annuity Pay System Records

FR Citation: 74 FR 696

Number of Respondents: 240

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 15 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	240	240
Annual IC Time Burden (Hours)	240	240
Annual IC Cost Burden (Dollars)	11,670	11,670

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.