Information Collection

Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants

IC 33692 under ICR 202109-0505-002 · OMB 0505-0024.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DPRS 2809 Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants	Form and Instruction
DPRS 2809 Request to Change FEHB or to Receive Plan Brochures for DRPS2809.pdf	Form and Instruction
DPRS 2809 Request to Change FEHB or to Receive Plan Brochures for DRPS2809.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:

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	DPRS 2809	Request to Change FEHB or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitant	DRPS2809.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: 45,000

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	45,000	20,000	25,000
Annual IC Time Burden (Hours)	33,750	15,000	18,750
Annual IC Cost Burden (Dollars)	0	0	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.