Information Collection

Disabled Dependent Questionnaire

IC 33661 under ICR 202106-3206-003 · OMB 3206-0179.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form RI 30-10 Disabled Dependent Questionnaire	Form and Instruction
RI 30-10 Disabled Dependent Questionnaire_MarkUp RI30-010_2018_05_MarkUp.pdf	Form and Instruction
RI 30-10 Disabled Dependent Questionnaire_MarkUp RI30-010_2018_05_MarkUp.pdf	Form and Instruction
RI 30-10 Disabled Dependent Questionnaire_Revised RI30-010_2021_09_Revised.pdf	Form and Instruction
RI 30-10 Disabled Dependent Questionnaire_Revised RI30-010_2021_09_Revised.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR Chp 1 Sect 843.406 - 843.410 (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	RI 30-10	Disabled Dependent Questionnaire_MarkUp	RI30-010_2018_05_MarkUp.pdf		Yes	No	Fillable Printable
Form and Instruction	RI 30-10	Disabled Dependent Questionnaire_Revised	RI30-010_2021_09_Revised.pdf		Yes	No	Fillable Printable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records

Title: OPM/Central-1

FR Citation: 73 FR 15013

Number of Respondents: 2,500

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,500	0	2,500
Annual IC Time Burden (Hours)	2,500	0	2,500
Annual IC Cost Burden (Dollars)	67,187	67,187	0

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.