Information Collection

Application for Survivor Death Benefits

IC 33838 under ICR 202204-3220-002 · OMB 3220-0031.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0031 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AA-21 (12-18) Application for Survivor Death Benefits	Form and Instruction
AA-21 (12-18) Application for Lump-Sum Death Payments and Annuities Un Form AA-21 (12-18).pdf	Form and Instruction
AA-21 (12-18) Application for Lump-Sum Death Payments and Annuities Un Form AA-21 (12-18).pdf	Form and Instruction
G-131 (12-18) Authorization of Payment and Release of All Claims to a Form G-131 (12-18).pdf	Form and Instruction
G-131 (12-18) Authorization of Payment and Release of All Claims to a Form G-131 (12-18).pdf	Form and Instruction
AA-21CERT (All Pos Application Summary and Certification Form AA-21 Cert - (08-18) All Possible.pdf	Form
AA-21CERT (All Pos Application Summary and Certification Form AA-21 Cert - (08-18) All Possible.pdf	Form
AA-21 (Proposed) Application for Lump-Sum Death Payment and Annuities Unp Form AA-21 (xx-xx) - Proposed.pdf	Form and Instruction
AA-21 (Proposed) Application for Lump-Sum Death Payment and Annuities Unp Form AA-21 (xx-xx) - Proposed.pdf	Form and Instruction
AA-21CERT Complete Application Summary and Certification Form AA-21 Cert - (08-18) Completed.pdf	Form
AA-21CERT Complete Application Summary and Certification Form AA-21 Cert - (08-18) Completed.pdf	Form
Form AA-11a (12-18).pdf AA-11a, Designation or Change of Beneficiary for Employees with Service Prior to January 1, 1975, for Residual Lump Sum	IC Document
Form AA-11a (12-18).pdf AA-11a, Designation or Change of Beneficiary for Employees with Service Prior to January 1, 1975, for Residual Lump Sum	IC Document
Form RB-21 (10-18).pdf RB-21, Lump-Sum Death Payment, Residual Lump-Sum, Annuities Unpaid at Death	IC Document
Form RB-21 (10-18).pdf RB-21, Lump-Sum Death Payment, Residual Lump-Sum, Annuities Unpaid at Death	IC Document
Form AA-21 Rec - (08-18) All Possible.pdf AA-21 - Application for Survivor Benefits - Receipt for Claim	IC Document
Form AA-21 Rec - (08-18) All Possible.pdf AA-21 - Application for Survivor Benefits - Receipt for Claim	IC Document
Form AA-21 Rec - (08-18) Completed.pdf AA-21 - Application for Survivor Benefits - Receipt for Claim	IC Document
Form AA-21 Rec - (08-18) Completed.pdf AA-21 - Application for Survivor Benefits - Receipt for Claim	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Application for Survivor Death Benefits

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 234 20 CFR 217 20 CFR 219

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	AA-21 (12-18)	Application for Lump-Sum Death Payments and Annuities Unpaid at Death	Form AA-21 (12-18).pdf	No	Paper Only
Form and Instruction	G-131 (12-18)	Authorization of Payment and Release of All Claims to a Death Benefit or Accrued Annuity Payment	Form G-131 (12-18).pdf	No	Paper Only
Form	AA-21CERT (All Possible)	Application Summary and Certification	Form AA-21 Cert - (08-18) All Possible.pdf	No	Paper Only
Form and Instruction	AA-21 (Proposed)	Application for Lump-Sum Death Payment and Annuities Unpaid at Death	Form AA-21 (xx-xx) - Proposed.pdf	No	Paper Only
Form	AA-21CERT Completed	Application Summary and Certification	Form AA-21 Cert - (08-18) Completed.pdf	No	Paper Only

Federal Enterprise Architecture Business Reference Module

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: 3,800

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 92 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	3,800	3,800
Annual IC Time Burden (Hours)	1,308	1,308
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
AA-11a, Designation or Change of Beneficiary for Employees with Service Prior to January 1, 1975, for Residual Lump Sum	Form AA-11a (12-18).pdf	03/18/2019
RB-21, Lump-Sum Death Payment, Residual Lump-Sum, Annuities Unpaid at Death	Form RB-21 (10-18).pdf	03/18/2019
AA-21 - Application for Survivor Benefits - Receipt for Claim	Form AA-21 Rec - (08-18) All Possible.pdf	04/22/2022
AA-21 - Application for Survivor Benefits - Receipt for Claim	Form AA-21 Rec - (08-18) Completed.pdf	04/29/2022

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