Information Collection

Benefits Package and Supporting Documentation

IC 208418 under ICR 202401-0915-002 · OMB 0915-0334.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0334 can be found here:

2026-03-19 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Compensation Attachment 1.docx	Instruction
Compensation Attachment 1.docx	Instruction
Compensation Attachment 1 for Reps.docx	Instruction
Compensation Attachment 1 for Reps.docx	Instruction
Compensation Attachment 1 for Estate.docx	Instruction
Compensation Attachment 1 for Estate.docx	Instruction
10162023 - (08) Recipient Requester Package - Compensation Letter - CLEAN.docx	Instruction
10162023 - (08) Recipient Requester Package - Compensation Letter - CLEAN.docx	Instruction
10162023 - (09) Recipient Requester Package - Attachment 1 - Documentation Required to Reimburse of Pay for Medical Expenses...	Instruction
10162023 - (09) Recipient Requester Package - Attachment 1 - Documentation Required to Reimburse of Pay for Medical Expenses...	Instruction
10162023 - (09) Recipient Requester Package - Attachment 1 - Documentation Required to Reimburse of Pay for Medical Expenses...	Instruction
10162023 - (09) Recipient Requester Package - Attachment 1 - Documentation Required to Reimburse of Pay for Medical Expenses...	Instruction
10162023 - (12) Estate Package - Compensation Letter - CLEAN.docx	Instruction
10162023 - (12) Estate Package - Compensation Letter - CLEAN.docx	Instruction
10162023 - (12) Estate Package - Compensation Letter - REDLINE.docx	Instruction
10162023 - (12) Estate Package - Compensation Letter - REDLINE.docx	Instruction
10162023 - (13) Estate Package - Attachment 1 - Compensation Attachment - CLEAN.docx	Instruction
10162023 - (13) Estate Package - Attachment 1 - Compensation Attachment - CLEAN.docx	Instruction
10162023 - (13) Estate Package - Attachment 1 - Compensation Attachment - REDLINE.docx	Instruction
10162023 - (13) Estate Package - Attachment 1 - Compensation Attachment - REDLINE.docx	Instruction
10162023 - (14) Survivor Package - Compensation Letter - CLEAN.docx	Instruction
10162023 - (14) Survivor Package - Compensation Letter - CLEAN.docx	Instruction
10162023 - (14) Survivor Package - Compensation Letter - REDLINE.docx	Instruction
10162023 - (14) Survivor Package - Compensation Letter - REDLINE.docx	Instruction
4.1 Certification of Status for Death Benefit – Alternate Ca Certification of Status for Death Benefit - Alternative Calculation.docx	Form
4.1 Certification of Status for Death Benefit – Alternate Ca Certification of Status for Death Benefit - Alternative Calculation.docx	Form
4.2 Certification of Status for Death Benefit - Standard Cal Certification of Status for Death Benefit - Standard Calculation.docx	Form
4.2 Certification of Status for Death Benefit - Standard Cal Certification of Status for Death Benefit - Standard Calculation.docx	Form
4.3 Certification of Survivor Relationship to Deceased Injur Death Benefit Certification of Relationship Survivor.docx	Form
4.3 Certification of Survivor Relationship to Deceased Injur Death Benefit Certification of Relationship Survivor.docx	Form
4.4 Certification of Status for Administrators of the Estate Lost Employment Income Certification - Estate.docx	Form
4.4 Certification of Status for Administrators of the Estate Lost Employment Income Certification - Estate.docx	Form
4.5 Certification of Status: Lost Employment Income Lost Employment Income Certification.docx	Form
4.5 Certification of Status: Lost Employment Income Lost Employment Income Certification.docx	Form
4.6 Certification of Status: Unreimbursed Medical Expenses Unreimbursed Medical Expenses Certification.docx	Form
4.6 Certification of Status: Unreimbursed Medical Expenses Unreimbursed Medical Expenses Certification.docx	Form
Attachment 2 Unreimbursed Medical Expenses Certification A (Clean) 10162023 - (10) Recipient Requester Package - Attachment 2 - Unreimbursed Medical Expenses Certification A - CLEAN.docx	Form and Instruction
Attachment 2 Unreimbursed Medical Expenses Certification A (Clean) 10162023 - (10) Recipient Requester Package - Attachment 2 - Unreimbursed Medical Expenses Certification A - CLEAN.docx	Form and Instruction
Attachment 2 Unreimbursed Medical Expenses Certification (Redline) 10162023 - (10) Recipient Requester Package - Attachment 2 - Unreimbursed Medical Expenses Certification A - REDLINE.docx	Form and Instruction
Attachment 2 Unreimbursed Medical Expenses Certification (Redline) 10162023 - (10) Recipient Requester Package - Attachment 2 - Unreimbursed Medical Expenses Certification A - REDLINE.docx	Form and Instruction
Attachment 3 Lost Employment Income Certification A (Clean) 10162023 - (11) Recipient Requester Package - Attachment 3 - Lost Employment Income Certification A - CLEAN.docx	Form and Instruction
Attachment 3 Lost Employment Income Certification A (Clean) 10162023 - (11) Recipient Requester Package - Attachment 3 - Lost Employment Income Certification A - CLEAN.docx	Form and Instruction
Attachment 3 Lost Income Certification A (Redline) 10162023 - (11) Recipient Requester Package - Attachment 3 - Lost Employment Income Certification A - REDLINE.docx	Form and Instruction
Attachment 3 Lost Income Certification A (Redline) 10162023 - (11) Recipient Requester Package - Attachment 3 - Lost Employment Income Certification A - REDLINE.docx	Form and Instruction
Attachment 2 - Est Unreimbrused Medical Expenses Certification (Clean) 10162023 - (15) Estate Package - Attachment 2 - Unreimbursed Medical Expenses Certification - CLEAN.docx	Form and Instruction
Attachment 2 - Est Unreimbrused Medical Expenses Certification (Clean) 10162023 - (15) Estate Package - Attachment 2 - Unreimbursed Medical Expenses Certification - CLEAN.docx	Form and Instruction
Attachment 2 - Est Unreimbursed Medical Expenses Certification (redline) 10162023 - (15) Estate Package - Attachment 2 - Unreimbursed Medical Expenses Certification - REDLINE.docx	Form and Instruction
Attachment 2 - Est Unreimbursed Medical Expenses Certification (redline) 10162023 - (15) Estate Package - Attachment 2 - Unreimbursed Medical Expenses Certification - REDLINE.docx	Form and Instruction
Attachment 3 - Est Lost Income Certification 10162023 - (16) Estate Package - Attachment 3 - Lost Employment Income Certification - CLEAN.docx	Form and Instruction
Attachment 3 - Est Lost Income Certification 10162023 - (16) Estate Package - Attachment 3 - Lost Employment Income Certification - CLEAN.docx	Form and Instruction
Attachment 1 - Sur Certifcation of Status for Death Benefit (clean) 10162023 - (17) Survivor Package - Attachment 1 - Certification of Status for Death Benefit - Standard Calculation - CLEAN.docx	Form and Instruction
Attachment 1 - Sur Certifcation of Status for Death Benefit (clean) 10162023 - (17) Survivor Package - Attachment 1 - Certification of Status for Death Benefit - Standard Calculation - CLEAN.docx	Form and Instruction
Attachment 1 - Sur Certification of Status for Death Benefit - Redline 10162023 - (17) Survivor Package - Attachment 1 - Certification of Status for Death Benefit - Standard Calculation - REDLINE.doc	Form and Instruction
Attachment 1 - Sur Certification of Status for Death Benefit - Redline 10162023 - (17) Survivor Package - Attachment 1 - Certification of Status for Death Benefit - Standard Calculation - REDLINE.doc	Form and Instruction
Attachment 2 - Sur Certification of Status for Death Benefit - Alternative 10162023 - (18) Survivor Package - Attachment 2 - Certification of Status for Death Benefit - Alternative Calculation - CLEAN.do	Form and Instruction
Attachment 2 - Sur Certification of Status for Death Benefit - Alternative 10162023 - (18) Survivor Package - Attachment 2 - Certification of Status for Death Benefit - Alternative Calculation - CLEAN.do	Form and Instruction
Attachment 2 - Sur Certification of Status for Death Benefit - Alternative 10162023 - (18) Survivor Package - Attachment 2 - Certification of Status for Death Benefit - Alternative Calculation - REDLINE.	Form and Instruction
Attachment 2 - Sur Certification of Status for Death Benefit - Alternative 10162023 - (18) Survivor Package - Attachment 2 - Certification of Status for Death Benefit - Alternative Calculation - REDLINE.	Form and Instruction
Attachment 3 - Sur Survivor Attachment 3 - Death Benefit Certification of R 10112023 - (19) Survivor Package - Attachment 3 - Death Benefit Certification of Relationship - REDLINE.docx	Form and Instruction
Attachment 3 - Sur Survivor Attachment 3 - Death Benefit Certification of R 10112023 - (19) Survivor Package - Attachment 3 - Death Benefit Certification of Relationship - REDLINE.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Benefits Package and Supporting Documentation

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Compensation Attachment 1.docx	Yes	Yes	Printable Only
Instruction			Compensation Attachment 1 for Reps.docx	Yes	Yes	Printable Only
Instruction			Compensation Attachment 1 for Estate.docx	Yes	Yes	Printable Only
Form	4.1	Certification of Status for Death Benefit â Alternate Calculation	Certification of Status for Death Benefit - Alternative Calculation.docx	Yes	Yes	Printable Only
Form	4.2	Certification of Status for Death Benefit - Standard Calculation	Certification of Status for Death Benefit - Standard Calculation.docx	Yes	Yes	Printable Only
Form	4.3	Certification of Survivor Relationship to Deceased Injured Countermeasure Recipient	Death Benefit Certification of Relationship Survivor.docx	Yes	Yes	Printable Only
Form	4.4	Certification of Status for Administrators of the Estate: Lost Employment Income	Lost Employment Income Certification - Estate.docx	Yes	Yes	Printable Only
Form	4.5	Certification of Status: Lost Employment Income	Lost Employment Income Certification.docx	Yes	Yes	Printable Only
Form	4.6	Certification of Status: Unreimbursed Medical Expenses	Unreimbursed Medical Expenses Certification.docx	Yes	Yes	Printable Only
Instruction			10162023 - (08) Recipient Requester Package - Compensation Letter - CLEAN.docx	Yes	Yes	Fillable Fileable
Instruction			10162023 - (09) Recipient Requester Package - Attachment 1 - Documentation Required to Reimburse of Pay for Medical Expenses... - CLEAN.docx	Yes	Yes	Fillable Fileable
Instruction			10162023 - (09) Recipient Requester Package - Attachment 1 - Documentation Required to Reimburse of Pay for Medical Expenses... - REDLINE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 2	Unreimbursed Medical Expenses Certification A (Clean)	10162023 - (10) Recipient Requester Package - Attachment 2 - Unreimbursed Medical Expenses Certification A - CLEAN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 2	Unreimbursed Medical Expenses Certification (Redline)	10162023 - (10) Recipient Requester Package - Attachment 2 - Unreimbursed Medical Expenses Certification A - REDLINE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 3	Lost Employment Income Certification A (Clean)	10162023 - (11) Recipient Requester Package - Attachment 3 - Lost Employment Income Certification A - CLEAN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 3	Lost Income Certification A (Redline)	10162023 - (11) Recipient Requester Package - Attachment 3 - Lost Employment Income Certification A - REDLINE.docx	Yes	Yes	Fillable Fileable
Instruction			10162023 - (12) Estate Package - Compensation Letter - CLEAN.docx	Yes	Yes	Fillable Fileable
Instruction			10162023 - (12) Estate Package - Compensation Letter - REDLINE.docx	Yes	Yes	Fillable Fileable
Instruction			10162023 - (13) Estate Package - Attachment 1 - Compensation Attachment - CLEAN.docx	Yes	Yes	Fillable Fileable
Instruction			10162023 - (13) Estate Package - Attachment 1 - Compensation Attachment - REDLINE.docx	Yes	Yes	Fillable Fileable
Instruction			10162023 - (14) Survivor Package - Compensation Letter - CLEAN.docx	Yes	Yes	Fillable Fileable
Instruction			10162023 - (14) Survivor Package - Compensation Letter - REDLINE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 2 - Estate	Unreimbrused Medical Expenses Certification (Clean)	10162023 - (15) Estate Package - Attachment 2 - Unreimbursed Medical Expenses Certification - CLEAN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 2 - Estate	Unreimbursed Medical Expenses Certification (redline)	10162023 - (15) Estate Package - Attachment 2 - Unreimbursed Medical Expenses Certification - REDLINE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 3 - Estate	Lost Income Certification	10162023 - (16) Estate Package - Attachment 3 - Lost Employment Income Certification - CLEAN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 1 - Survivor	Certifcation of Status for Death Benefit (clean)	10162023 - (17) Survivor Package - Attachment 1 - Certification of Status for Death Benefit - Standard Calculation - CLEAN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 1 - Survivor	Certification of Status for Death Benefit - Redline	10162023 - (17) Survivor Package - Attachment 1 - Certification of Status for Death Benefit - Standard Calculation - REDLINE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 2 - Survivor	Certification of Status for Death Benefit - Alternative Calculation (Clean)	10162023 - (18) Survivor Package - Attachment 2 - Certification of Status for Death Benefit - Alternative Calculation - CLEAN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 2 - Survivor	Certification of Status for Death Benefit - Alternative Calculation (redline)	10162023 - (18) Survivor Package - Attachment 2 - Certification of Status for Death Benefit - Alternative Calculation - REDLINE.docx	Yes	Yes	Fillable Fileable
Form and Instruction	Attachment 3 - Survivor	Survivor Attachment 3 - Death Benefit Certification of Relationship Redline	10112023 - (19) Survivor Package - Attachment 3 - Death Benefit Certification of Relationship - REDLINE.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 30

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	4	4
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.