Information Collection

Employee's Certification

IC 33938 under ICR 202111-3220-001 · OMB 3220-0140.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0140 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form G-346 (03-18) Employee's Certification	Form
G-346 (03-18) Employee's Certification Form G-346 (03-18).pdf	Form
G-346 (03-18) Employee's Certification Form G-346 (03-18).pdf	Form
G-346sum (03-18) Employee's Certification Summary Form G-346sum All (03-18).pdf	Form
G-346sum (03-18) Employee's Certification Summary Form G-346sum All (03-18).pdf	Form
G-346sum (03-18) Employee's Certification Summary Form G-346sum Completed (03-18).pdf	Form
G-346sum (03-18) Employee's Certification Summary Form G-346sum Completed (03-18).pdf	Form
Form AA-7 (01-18).pdf AA-7, Spouse/Divorced Spouse Application for Medicare	IC Document
Form AA-7 (01-18).pdf AA-7, Spouse/Divorced Spouse Application for Medicare	IC Document
Form AA-3 (07-17).pdf AA-3, Application for Spouse/Divorced Spouse Annuity	IC Document
Form AA-3 (07-17).pdf AA-3, Application for Spouse/Divorced Spouse Annuity	IC Document

IC Title:

Employee's Certification

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 219.30 - 219.35 20 CFR 217(17)(f)(3) (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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	G-346 (03-18)	Employee's Certification	Form G-346 (03-18).pdf	No		Paper Only
Form	G-346sum (03-18)	Employee's Certification Summary	Form G-346sum All (03-18).pdf	Yes	No	Printable Only
Form	G-346sum (03-18)	Employee's Certification Summary	Form G-346sum Completed (03-18).pdf	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records

Title: RRB-22, Railroad Retirement, Survivor and Pensioner Benefit System

FR Citation: 79 FR 58874

Number of Respondents: 5,560

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 40 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,560	-760	6,320
Annual IC Time Burden (Hours)	488	-39	527
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
AA-7, Spouse/Divorced Spouse Application for Medicare	Form AA-7 (01-18).pdf	11/30/2021
AA-3, Application for Spouse/Divorced Spouse Annuity	Form AA-3 (07-17).pdf	10/03/2018

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