Information Collection

Application for Survivor Insurance Annuities

IC 33834 under ICR 202411-3220-011 · OMB 3220-0030.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AA-17b (10-07) Application for Determination of Widow(ers) Disability Application for Survivor Insurance Annuities	Form and Instruction
Form AA-19a (10-07) Application for Determination of Child's Disability Application for Survivor Insurance Annuities	Form and Instruction
Form AA-17cert (09-15)( Application Summary and Certification Application for Survivor Insurance Annuities	Form
Form AA-17cert (09-15) Application Summary and Certification Application for Survivor Insurance Annuities	Form
Form AA-17sum (01-19) ( Application Summary Application for Survivor Insurance Annuities	Form
Form AA-17sum (01-19) ( Application Summary Application for Survivor Insurance Annuities	Form
Form AA-17b (XX-XX) - P Application for Determination of Widow(ers) Disability Application for Survivor Insurance Annuities	Form and Instruction
Form AA-19a (XX-XX) - P Application for Determination of Child's Disability Application for Survivor Insurance Annuities	Form and Instruction
AA-17b (10-07) Application for Determination of Widow(ers) Disability AA-17b (06-19) CURRENT.pdf	Form and Instruction
AA-19a (10-07) Application for Determination of Child's Disability AA-19a(06-19) CURRENT.pdf	Form and Instruction
AA-17cert (09-15)( Application Summary and Certification Form AA-17cert (09-15) (All Possible).pdf	Form
AA-17cert (09-15) Application Summary and Certification Form AA-17cert (09-15) (Completed).pdf	Form
AA-17sum (01-19) ( Application Summary Form AA-17sum (01-19) (All Possible).pdf	Form
AA-17sum (01-19) ( Application Summary Form AA-17sum (01-19) (Completed).pdf	Form
AA-17b (XX-XX) - P Application for Determination of Widow(ers) Disability AA-17b (xx-xx) Proposed.pdf	Form and Instruction
AA-19a (XX-XX) - P Application for Determination of Child's Disability AA-19a (xx-xx) Proposed.pdf	Form and Instruction
RB-3 (11-08).pdf RB-3 Booklet; Furnishing Evidence to Support Your Claim	IC Document
RB-17 (03-19).pdf RB-17 Booklet, Survivor Annuities	IC Document
RB-17b (03-19).pdf RB-17b Booklet; Widow(ers) Disability Benefits	IC Document
RB-19a (03-19).pdf RB-19A Booklet; Child's Disability Benefits	IC Document
Form AA-17rec (01-19).pdf AA-17rec; Receipt for Claim	IC Document
Form RL-1S (08-18).pdf RL-1S, Transmittal Letter for Self-administered Retirement Applications	IC Document
Form AA-17 (11-18).pdf AA-17, Application for Widow(ers) Annuity	IC Document
Form AA-18 (11-18).pdf AA-18, Application for Mother's/Father's and Child's Annuity	IC Document
Form AA-19 (11-18).pdf AA-19, Application for Child's Annuity	IC Document
Form AA-20 (11-18).pdf AA-20, Application for Parent's annuity	IC Document
RB-9s (03-09).pdf RB-9s, Events that Affect a Survivor Annuity	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Application for Survivor Insurance Annuities

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 216 20 CFR 218 20 CFR 219 20 CFR 217

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	AA-17b (10-07)	No		Paper Only
Form and Instruction	AA-19a (10-07)	No		Paper Only
Form	AA-17cert (09-15)(all possible)	Yes	Yes	Printable Only
Form	AA-17cert (09-15)	Yes	Yes	Printable Only
Form	AA-17sum (01-19) (All possible)	Yes	Yes	Printable Only
Form	AA-17sum (01-19) (Completed)	Yes	Yes	Printable Only
Form and Instruction	AA-17b (XX-XX) - Proposed	No		Paper Only
Form and Instruction	AA-19a (XX-XX) - Proposed	No		Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System

FR Citation: 79 FR 58874

Number of Respondents: 3,410

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 86 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,410	-75	3,485
Annual IC Time Burden (Hours)	1,314	-23	1,337
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
RB-3 Booklet; Furnishing Evidence to Support Your Claim		07/16/2009
RB-17 Booklet, Survivor Annuities		06/13/2022
RB-17b Booklet; Widow(ers) Disability Benefits		03/15/2019
RB-19A Booklet; Child's Disability Benefits		03/15/2019
AA-17rec; Receipt for Claim		12/21/2018
RL-1S, Transmittal Letter for Self-administered Retirement Applications		03/18/2019
AA-17, Application for Widow(ers) Annuity		12/21/2018
AA-18, Application for Mother's/Father's and Child's Annuity		12/21/2018
AA-19, Application for Child's Annuity		12/21/2018
AA-20, Application for Parent's annuity		12/21/2018
RB-9s, Events that Affect a Survivor Annuity		03/18/2019

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

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