Information Collection

Application for Court-Ordered Benefits for Former Spouses

IC 243243 under ICR 202008-3206-001 · OMB 3206-0275.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Standard Form 3119 Application for Court-Ordered Benefits for Former Spouses 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	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

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Standard Form 3119			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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
60 Day Federal Register Notice		08/19/2020
30 Day Federal Register Notice		08/19/2020
Privacy Impact Assessment Annuity Roll System		08/19/2020
Systems of Records Notice		08/19/2020

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

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