Application for Court-Ordered Benefits for Former Spouses

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

Documents and Forms

Document Name Document Type
Form Standard Form 3119 Application for Court-Ordered Benefits for Former Spouses Form and Instruction
Standard Form 3119 Application for Court-Ordered Benefits for Former Spouse SF3119_2020_11.pdf www.opm.gov Form and Instruction
SF3119_60DayFRNPublished_2020_03_23.pdf 60 Day Federal Register Notice IC Document
2020-15455.pdf 30 Day Federal Register Notice IC Document
ARS PIA Final 12212017signed.pdf Privacy Impact Assessment Annuity Roll System IC Document
E8-5659.pdf Systems of Records Notice IC Document

Information Collection (IC) Details

IC Title:	Application for Court-Ordered Benefits for Former Spouses	Agency IC Tracking Number:	SF 3119

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 5 CFR 838, Sub-parts B, D and G (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Standard Form 3119	Application for Court-Ordered Benefits for Former Spouses	SF3119_2020_11.pdf	www.opm.gov	Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records
Title: OPM/Central 1	FR Citation: 73 FR 15013

Number of Respondents: 19,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	19,000	19,000
Annual IC Time Burden (Hours)	9,500	9,500
Annual IC Cost Burden (Dollars)	255,229	255,229

Documents for IC

Title	Document	Date Uploaded
60 Day Federal Register Notice	SF3119_60DayFRNPublished_2020_03_23.pdf	08/19/2020
30 Day Federal Register Notice	2020-15455.pdf	08/19/2020
Privacy Impact Assessment Annuity Roll System	ARS PIA Final 12212017signed.pdf	08/19/2020
Systems of Records Notice	E8-5659.pdf	08/19/2020

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