Application for Survivor Insurance Annuities

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form AA-17sum (01-19) ( Application Summary	Form	Unchanged	Available
Form AA-17sum (01-19) ( Application Summary	Form	Unchanged	Available
Form AA-17cert (09-15) Application Summary and Certification	Form	Unchanged	Available
Form AA-17cert (09-15)( Application Summary and Certification	Form	Unchanged	Available
Form AA-19a (10-07) Application for Determination of Child's Disability	Form and Instruction	Unchanged	Available
Form AA-17b (10-07) Application for Determination of Widow(ers) Disability	Form and Instruction	Unchanged	Available
Form AA-17b (10-07) Application for Survivor Insurance Annuities	Form and Instruction	Unchanged	Repair queued
Request OMB Approval of NonSubstantive Change to ICR 3220-0030_Signed.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2024-04-03	Available
Request OMB Approval of NonSubstantive Change to ICR 3220-0030_Signed.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2024-04-03	Repair queued
3220-0030.docx	Supporting Statement A	Uploaded 2022-06-13	Available
3220-0030.docx	Supporting Statement A	Uploaded 2022-06-13	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
33834	Application for Survivor Insurance Annuities	Form	Unchanged	Application Summary
33834	Application for Survivor Insurance Annuities	Form	Unchanged	Application Summary
33834	Application for Survivor Insurance Annuities	Form	Unchanged	Application Summary and Certification
33834	Application for Survivor Insurance Annuities	Form	Unchanged	Application Summary and Certification
33834	Application for Survivor Insurance Annuities	Form and Instruction	Unchanged	Application for Determination of Child's Disability
33834	Application for Survivor Insurance Annuities	Form and Instruction	Unchanged	Application for Determination of Widow(ers) Disability
33834	Application for Survivor Insurance Annuities	Form and Instruction	Unchanged

ICR Details

OMB Control No: 3220-0030	ICR Reference No: 202404-3220-001
Status: Historical Active	Previous ICR Reference No: 202206-3220-002
Agency/Subagency: RRB	Agency Tracking No:
Title: Application for Survivor Insurance Annuities
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/22/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/03/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2025	09/30/2025	09/30/2025
Responses	3,485	0	3,485
Time Burden (Hours)	1,337	0	1,337
Cost Burden (Dollars)	0	0	0

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Abstract: Under Section 2(d) of the Railroad Retirement Act, monthly survivor annuities are payable to surviving widow(er)s, parents, unmarried children, and in certain cases, divorced wives (husbands), mothers (fathers), remarried widow(er)s and grandchildren of deceased railroad employees. The collection obtains information needed by the RRB to determine entitlement to and the amount of the annuity applied for.

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Authorizing Statute(s): US Code: 45 USC 231f Name of Law: Railroad Retirement Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 19538	04/04/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 35805	06/13/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Application for Survivor Insurance Annuities	AA-17cert (09-15)(all possible), AA-17b (10-07), AA-19a (10-07), AA-17cert (09-15), AA-17sum (01-19) (Completed), AA-17sum (01-19) (All possible)	Application for Determination of Widow(ers) Disability ,   Application for Determination of Child's Disability ,   Application Summary and Certification ,   Application Summary and Certification ,   Application Summary ,   Application Summary

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,485	3,485	0	0	0	0
Annual Time Burden (Hours)	1,337	1,337	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/03/2024

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