Application for Court-Ordered Benefits for Former Spouses, Standard Form 3119

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Standard Form 3119 Application for Court-Ordered Benefits for Former Spouses	Form and Instruction	New	Available
E8-5659.pdf	Supplementary Document	Uploaded 2020-08-19	Available
ARS PIA Final 12212017signed.pdf	Supplementary Document	Uploaded 2020-08-19	Available
2020-15455.pdf	Supplementary Document	Uploaded 2020-08-19	Available
SF3119_60DayFRNPublished_2020_03_23.pdf	Supplementary Document	Uploaded 2020-08-19	Available
SF3119_OMBSupportingStatement_2020_06_18.docx	Supporting Statement A	Uploaded 2020-08-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
243243	Application for Court-Ordered Benefits for Former Spouses	Form and Instruction	New

ICR Details

OMB Control No: 3206-0275	ICR Reference No: 202008-3206-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: OPM	Agency Tracking No: SF 3119
Title: Application for Court-Ordered Benefits for Former Spouses, Standard Form 3119
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/09/2020
	Date Received in OIRA: 10/06/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2023	36 Months From Approved
Responses	19,000	0	0
Time Burden (Hours)	9,500	0	0
Cost Burden (Dollars)	255,229	0	0

---

Abstract: 5 CFR 838.221, 838.421, and 838.721 require former spouses of Federal employees to write to OPM, providing specific information needed for OPM to make court-ordered benefit payments. This information is needed to identify affected employees and to certify that the court order remains in effect.

---

Authorizing Statute(s): US Code: 5 USC 8345(j), 8341(h), 8445, 8467 Name of Law: null
  

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:
	85 FR 16395	03/23/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 43612	07/17/2020
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
Application for Court-Ordered Benefits for Former Spouses	Standard Form 3119	Application for Court-Ordered Benefits for Former Spouses

---

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	19,000	0	0	19,000	0	0
Annual Time Burden (Hours)	9,500	0	0	9,500	0	0
Annual Cost Burden (Dollars)	255,229	0	0	255,229	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Calculation for Cost Burden

---

Annual Cost to Federal Government: $14,590

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? No

---

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: 10/06/2020

---