Information Collection

Health Benefits Election Form

IC 33632 under ICR 202203-3206-004 · OMB 3206-0160.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3206-0160 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SF 2809 Health Benefits Election Form	Form and Instruction
SF 2809 Health Benefits Election Form SF2809_2019_01_Revised.pdf	Form and Instruction
SF 2809 Health Benefits Election Form SF2809_2019_01_Revised.pdf	Form and Instruction
SF 2809 Health Benefits Election Form SF2809_2015_11_MarkUp.pdf www.opm.gov/forms/pdf_fill/sf2809.pdf	Form and Instruction
SF 2809 Health Benefits Election Form SF2809_2015_11_MarkUp.pdf www.opm.gov/forms/pdf_fill/sf2809.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Health Benefits Election Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 890-1105 through 890.1110 5 CFR 890.301 through 890-307 5 CFR 890.805 through 809.807 (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	SF 2809	Health Benefits Election Form	SF2809_2019_01_Revised.pdf		Yes	No	Fillable Printable
Form and Instruction	SF 2809	Health Benefits Election Form	SF2809_2015_11_MarkUp.pdf	https://www.opm.gov/forms/pdf_fill/sf2809.pdf	Yes	No	Fillable Printable

Federal Enterprise Architecture Business Reference Module

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: 18,000

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	Previously Approved
Annual Number of Responses for this IC	18,000	18,000
Annual IC Time Burden (Hours)	9,000	9,000
Annual IC Cost Burden (Dollars)	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.