SF3104_OMB_Supporting_Stmt_2022_4_19

OMB SUPPORTING STATEMENT

SF 3104, Application for Death Benefits – (FERS)

SF 3104B, Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death

1. Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

Title 5, U.S. Code, Chapter 84, provides several types of death benefits payable upon the death of Federal employees, former employees and annuitants covered by FERS. The type(s) of benefit(s) payable depends on the amount of creditable Federal service the deceased performed, his/her status at death (i.e., employee, former employee or annuitant), the relationship of the applicant to the deceased and in the case of annuitants, any election(s) made regarding survivor benefits.

Upon the death of an employee, a survivor annuity may be payable to a spouse, former spouse (by court order) and/or eligible dependent children. If the deceased employee completed at least 18 months of creditable service, the spouse (or former spouse by court order) is eligible for the basic employee death benefit which is payable in either a lump sum or 36 monthly installments. If the employee completed at least 10 years of creditable service, the spouse (or former spouse if payable by court order) is also eligible for a monthly survivor annuity. Children of deceased employees are eligible for a monthly survivor annuity, if the deceased employee completed 18 months of service and the child meets certain criteria. A lump sum benefit is payable to the individual entitled under 5 U.S.C. 8424(d) if no other benefits are payable.

Upon the death of an annuitant, the spouse (or former spouse) is eligible for a monthly survivor annuity if elected by the annuitant at retirement or court-ordered in the case of a former spouse. Children of deceased annuitants are also eligible for a monthly survivor annuity if certain criteria are met. A lump sum benefit may also be payable, regardless of whether a survivor is payable.

Upon the death of a former employee, the spouse who was married to the former employee at the time of his/her separation from Federal service and/or former spouse (if payable by court order) are eligible for a monthly survivor benefit or a lump sum payment of the amount in the former employee’s retirement account if the former employee completed 10 years of creditable service. If no monthly survivor annuity is payable, a lump sum benefit may be payable to the individual entitled under 5 U.S.C. 8424(d).

These benefits cannot be paid unless application for the benefits is made to the Office of Personnel Management.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

SF 3104 is used by all survivors who apply for FERS death benefits, including former spouses. The information collected via this application is used by the Office of Personnel Management, Federal Employees Retirement System, to determine whether a benefit is payable in the event of the death of an employee, a former employee, or an annuitant. Sufficient information must be collected to identify the deceased. Information from applicants for monthly benefits must be collected to establish their relationship to the deceased, the age of the applicant, whether the applicant could be in receipt of any other Federal benefit which would bar payment of survivor annuity, and the existence and whereabouts of minor children who are payable. Applicants for lump sum payments are asked to supply information to establish their relationship to the deceased, the existence and whereabouts of other heirs, and whether there is a court-appointed executor or administrator of the estate. Information is also collected regarding the address of the applicant.

Since the amount of the benefit depends on the amount of service performed by the deceased, information is collected from survivors of deceased employees about whether a deposit has been paid for any active military service the deceased performed after 12/31/56 and whether the deceased was receiving or had waived military retired pay. This information about military service is already available to OPM in the case of deceased annuitants.

Benefits to children are contingent upon the total amount payable to children of the deceased under Title II of the Social Security Act. Therefore, parents or guardians of minor children are asked to submit verification of entitlement or lack of entitlement to social security benefits.

SF 3104A (attached to the SF 3104), requests information from the survivor which is used by OPM to determine entitlement of an applicant for a survivor annuity supplement (supplementary annuity).

SF 3104B is used by the deceased employee’s former employing agency in death-in-service cases, to supply OPM with the information necessary to support the survivor’s application for death benefits (SF 3104). The form is divided into six sections. Section 1 (Certified Summary of Federal Service) and Section 6 (Agency Information and Certification) are completed by the decedent’s employing agency’s personnel office. On the form in Section 1, the agency provides a certified history of the decedent’s Federal service to be used to determine the correct benefit(s) payable to the survivor. Section 6 contains a checklist which the agency’s payroll and personnel offices complete providing information regarding the decedent’s retirement coverage, receipt of benefits from the Office of Workers’ Compensation Programs (OWCP), and information regarding the decedent’s health and life insurance coverage. A checklist is also included informing the agency of all documentation which must be attached to the survivor’s application. The forms found in Sections 2 (Basic Employee Death Benefit), 3 (Health Benefits Election) and 4 (Information and Elections Regarding Post-1956 Military Service) are completed by both the decedent’s employing agency and the applicant(s), and Section 5 (Rollover Option Information) is completed by the applicant(s), providing OPM with certain elections which need to be made by the applicant(s) prior to the completion of their claim for benefits. The collection of this information with the Application for Death Benefits allows OPM to process claims for death benefits more quickly than if the information and elections were requested after the Application for Death Benefits was received.

The SF 3104 and the SF 3104B are separate forms since the SF 3104B is only used by individuals applying for death benefits based on the death of an employee, whereas the SF 3104 is used to apply for benefits based on the death of annuitants, employees and former employees.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

New methods of information collection technology will do little to reduce the burden as the information collected is detailed and can only be obtained from the respondents, who sign the application attesting to its truth, under penalty of law, to the best of their knowledge. However, these forms are available in a PDF fillable format on our website and meet our GPEA requirements.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

OPM has the sole authority to collect this information; therefore, duplication is minimized. Up-to-date, similar information certified by the applicant is not available.

5. If the collection of information impacts small businesses or other small entities
   (Item 5 of OMB Form 83-I), describe any methods used to minimize.

This information collection request has no impact on small businesses and organizations.

6. Describe the consequence to Federal/DHS program or policy activities if the collection of information is not conducted, or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

This information collection is required upon the death of an employee. Less frequent collections would delay the award of benefits authorized by Title 5, U.S. Code, Chapter 84.

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records, for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secrets, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information’s confidentiality to the extent permitted by law.

There are no special circumstances involved in the collection of this information.

8. Federal Register Notice: Provide a copy and identify the date and page number of the publication in the Federal Register of the agency’s notice soliciting comments on the information collection prior to submission to OMB.

On February 18, 2022, a 60 Day Federal Register Notice was published at 87 FR 9397. No comments were received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No gifts or payments of any kind have been provided to any individuals who are connected to this collection.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

This information collection is protected by the Privacy Act of 1974 and OPM regulations
(5 CFR 831.106). The routine uses of disclosure appear in the Federal Register for OPM/Central-1 (73 FR 15013, et seq., March 20, 2008, effective April 21, 2008).

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

This information collection does not include questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.

12. Provide estimates of the hour burden of the collection of information. The statement
    should:

a. Indicate the number of respondents, frequency of response, annual hour burden,
and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desired. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

b. If this request for approval covers more than one form, provide separate hour
burden estimates for each form and aggregate the hour burdens in Item 13 of OMB Form 83-I.

c. Provide estimates of annualized cost to respondents for the hour burdens for
collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

Approximately 12,734 Standard Form 3104s (Application for Death Benefits) are

expected to be processed annually. The form requires approximately 60 minutes to

complete, including the time for reviewing instructions, getting the needed data, and

reviewing the completed form. An annual burden of 12,734 hours is estimated.

Approximately 4,017 SF 3104Bs (Documentation and Elections in Support of

Application for Death Benefits when Deceased was an Employee at the Time of Death)

are expected to be processed annually. It is estimated that the form requires

approximately 60 minutes for completion. An annual burden of 4,017 hours is

estimated. The total annual burden is 16,751.

Form Name	Form Number	No. of Respondents	No. of Responses per Respondent	Average Burden per Response (in hours)	Total Annual Burden (in hours)	Average Hourly Wage Rate	Total Annual Respondent Cost
Application for Death Benefits (FERS)	SF 3104	12,734	1	1 hour	12,734	$10.75	$171,114
Documentation and Elections in Support of Application for Death Benefits when Deceased was an Employee at the Time of Death	SF 3104B	4,017	1	1 hour	4,017	$10.75	$53,943

In the past, we have interpreted The Total Annual Respondent Cost (TARC) as zero.

OMB has a new point of emphasis that the respondent cost would capture/calculate

indirect costs beyond burden time to complete the information collection.

The Total Annual Respondent Cost is $225,057.

13. Provide an estimate of the total annual cost burden to respondents or record-keepers
resulting from the collection of information. (Do not include the cost of any hour burden
shown in Items 12 and 14.)

The cost estimate should be split into two components: (1) a total capital and start-up

cost component (annualized over its expected useful life); and (b) a total operation and

maintenance and purchase of services component. The estimates should take into

account costs associated with generating, maintaining, and disclosing or providing the

information. Include descriptions of methods used to estimate major cost factors

including system and technology acquisition, expected useful life of capital equipment,

the discount rate(s), and the time period over which costs will be incurred. Capital and

start-up costs include, among other items, preparations for collecting information such

as purchasing computers and software; monitoring, sampling, drilling and testing

equipment; and record storage facilities.

If cost estimates are expected to vary widely, agencies should present ranges of cost

burdens and explain the reasons for the variance. The cost of purchasing or contracting

out information collection services should be a part of this cost burden estimate. In

developing cost burden estimates, agencies may consult with a sample of respondents

(fewer than 10), utilize the 60-day pre-OMB submission public comment process and

use existing economic or regulatory impact analysis associated with the rulemaking

containing the information collection as appropriate.

Generally, estimates should not include purchases of equipment or services, or portions

thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with

requirements not associated with the information collection, (3) for reasons other than to

provide information to keep records for the government, or (4) as part of customary and

usual business or private practices.

There are no changes in respondent burden.

14. Provide estimates of annualized cost to the Federal Government. Also, provide a

description of the method used to estimate cost, which should include quantification of

hours, operational expenses (such as equipment, overhead, printing and support staff),

and any other expense that would have been incurred without this collection of
information. You may also aggregate cost estimates for Items 12, 13 and 14 in a single

table.

The annualized cost to the Federal Government is $332,675. This cost is derived from

employee salaries, staff hours required to process the forms and the cost of printing,

storing and shipping forms.

15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of
the OMB Form 83-I. Changes in hour burden, i.e., program changes or adjustments made
to annual reporting and recordkeeping hour and cost burden. A program change is the
result of deliberate Federal government action. All new collections and any subsequent
revisions of existing collections (e.g., the addition or deletion of questions) are recorded
as program changes. An adjustment is a change that is not the result of a deliberate
Federal government action. These changes that result from new estimates or actions not
controllable by the Federal government are recorded as adjustments.

There is no change in the hour or cost burden.

16. For collections of information whose results will be published, outline plans for
tabulation and publication. Address any complex analytical techniques that will be used.
Provide the time schedule for the entire project, including beginning and ending dates of
the collection of information, completion of report, publication dates, and other actions.

The results of this information collection are not published.

17. If seeking approval to not display the expiration date for OMB approval of the
information collection, explain reasons that display would be inappropriate.

The Retirement Services program office is the lone processor of the data collected on these ICRs from approximately 2.8 million customers. The substance of each information collection does not substantively change at each OMB renewal cycle, but according to changes in law and regulation. These forms are printed and published (internet, intranet and on-board systems) through various agencies for distribution to and implementation by Government customers. Pursuant to title 5 CFR 1320.8(b)(1), it would not be appropriate to display the OMB clearance expiration date where the form will not be revised for the foreseeable future (e.g., because it is used to collect applicant, annuitant, or beneficiary information required by long-standing statutory provisions), where use of the paper form is prevalent, and where, accordingly, it will be expensive and burdensome to restock the paper forms inventory with a new version. Last year, under current practice, Retirement Services printed approximately 2 million documents subject to OMB clearance at a cost of approximately $85,000. Our costs would rise substantially if additional revision cycles are added. Lastly, by adding the OMB clearance expiration date to the existing format, the end users of OPM’s ICRs may erroneously assume that the expiration date affects the validity of the information collection when it is the OMB clearance expiration date and not reflective of the substance. This may lead to additional submissions by customers, possible litigation and increasing pressures on our Operations workloads. Therefore, we seek approval to not display the OMB clearance expiration date on the forms and to communicate version changes to the public via the revision date.

18. Explain each exception to the certification statement identified in Item 19 “Certification
for Paperwork Reduction Act Submissions,” of OMB Form 83-I.

There are no exceptions to the certification statement.