Health Benefits Election Form

Health Benefits Election Form

OMB: 3206-0160

IC ID: 33632

Information Collection (IC) Details

View Information Collection (IC)

Health Benefits Election Form
 
No Unchanged
 
Required to Obtain or Retain Benefits
 
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.)

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

General Government Executive Functions

OPM/Central-1  73 FR 15013

18,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 18,000 0 0 0 0 18,000
Annual IC Time Burden (Hours) 9,000 0 0 0 0 9,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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