Employee's Certification

Documents and Forms

Document Name Document Type
Form G-346 (03-18) Employee's Certification Form
G-346 (03-18) Employee's Certification Form G-346 (03-18).pdf Form
G-346sum (03-18) Employee's Certification Summary Form G-346sum All (03-18).pdf Form
G-346sum (03-18) Employee's Certification Summary Form G-346sum Completed (03-18).pdf Form
Form G-346 (XX-XX) Employee's Certification Form G-346 (XX-XX) Proposed.docx Form and Instruction
Form AA-7 (01-18).pdf AA-7, Spouse/Divorced Spouse Application for Medicare IC Document
Form AA-3 (07-17).pdf AA-3, Application for Spouse/Divorced Spouse Annuity IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Employee's Certification	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 219.30 - 219.35 20 CFR 217(17)(f)(3) (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	G-346 (03-18)	Employee's Certification	Form G-346 (03-18).pdf	No		Paper Only
Form	G-346sum (03-18)	Employee's Certification Summary	Form G-346sum All (03-18).pdf	Yes	No	Printable Only
Form	G-346sum (03-18)	Employee's Certification Summary	Form G-346sum Completed (03-18).pdf	Yes	No	Printable Only
Form and Instruction	Form G-346 (XX-XX) Proposed	Employee's Certification	Form G-346 (XX-XX) Proposed.docx	No		Paper Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title: RRB-22, Railroad Retirement, Survivor and Pensioner Benefit System	FR Citation: 79 FR 58874

Number of Respondents: 4,020	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 49 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	4,020	-1,540	5,560
Annual IC Time Burden (Hours)	335	-153	488
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
AA-7, Spouse/Divorced Spouse Application for Medicare	Form AA-7 (01-18).pdf	11/30/2021
AA-3, Application for Spouse/Divorced Spouse Annuity	Form AA-3 (07-17).pdf	10/03/2018

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