Information Collection

Physician Certificate for Child Annuitant

IC 5643 under ICR 202306-0730-003 · OMB 0730-0011.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD 2828 Physician Certificate for Child Annuitant Physician Certificate for Child Annuitant	Form
Request form.doc	Other-Request form
Request form.doc	Other-Request form
DD 2828 Physician Certificate for Child Annuitant DD2828 20170403 old address.PDF www.dtic.mil/whs/directives/forms/index.htm	Form
DD 2828 Physician Certificate for Child Annuitant DD2828 20170403 old address.PDF www.dtic.mil/whs/directives/forms/index.htm	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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
Other-Request form					No		Paper Only
Form	DD 2828			http://www.dtic.mil/whs/directives/forms/index.htm	Yes	No	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title: Defense Military Retiree and Annuity Pay System Records

FR Citation: 74 FR 696

Number of Respondents: 240

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 15 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	240	0	240
Annual IC Time Burden (Hours)	240	0	240
Annual IC Cost Burden (Dollars)	12,870	1,200	11,670

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.

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