Application for Survivor Death Benefits

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form AA-21CERT Complete Application Summary and Certification	Form	Modified	Available
Form AA-21 (Proposed) Application for Lump-Sum Death Payment and Annuities Unpaid at Death	Form and Instruction	Modified	Available
Form AA-21CERT (All Pos Application Summary and Certification	Form	Modified	Repair queued
Form G-131 (12-18) Authorization of Payment and Release of All Claims to a Death Benefit or Accrued Annuity Payment	Form and Instruction	Modified	Available
Form AA-21 (12-18) Application for Survivor Death Benefits	Form and Instruction	Modified	Repair queued
Form G-273A (Proposed) Funeral Director's Statement of Burial Expenses	Form and Instruction	Modified	Available
Form G-273A (Proposed) Funeral Director's Statement of Burial Expenses	Form	Modified	Repair queued
Form G-273a (06-19) Funeral Director's Statement of Burial Charges	Form and Instruction	Modified	Repair queued
Form G-273A (xx-xx) - Proposed 08082025.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2025-08-08	Available
Form AA-21 (xx-xx) - Proposed 08082025.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2025-08-08	Available
Request OMB Approval of NonSubstantive Change to ICR 3220-0031_Signed.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2025-08-08	Available
3220-0031 OMB Changes.docx	Supporting Statement A	Uploaded 2025-08-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
33838	Application for Survivor Death Benefits	Form	Modified	Application Summary and Certification
33838	Application for Survivor Death Benefits	Form and Instruction	Modified	Application for Lump-Sum Death Payment and Annuities Unpaid at Death
33838	Application for Survivor Death Benefits	Form	Modified	Application Summary and Certification
33838	Application for Survivor Death Benefits	Form and Instruction	Modified	Authorization of Payment and Release of All Claims to a Death Benefit or Accrued Annuity Payment
33838	Application for Survivor Death Benefits	Form and Instruction	Modified
189282	Funeral Director's Statement of Burial Charges	Form and Instruction	Modified	Funeral Director's Statement of Burial Expenses
189282	Funeral Director's Statement of Burial Charges	Form	Modified	Funeral Director's Statement of Burial Expenses
189282	Funeral Director's Statement of Burial Charges	Form and Instruction	Modified

ICR Details

OMB Control No: 3220-0031	ICR Reference No: 202508-3220-001
Status: Historical Active	Previous ICR Reference No: 202204-3220-002
Agency/Subagency: RRB	Agency Tracking No:
Title: Application for Survivor Death Benefits
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: 08/08/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/08/2025
Terms of Clearance: In accordance with 5 CFR 1320, this information collection change request is approved. Any previous terms of clearance remain in effect if applicable.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2025	11/30/2025	11/30/2025
Responses	7,800	0	7,800
Time Burden (Hours)	1,975	0	1,975
Cost Burden (Dollars)	0	0	0

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Abstract: The collection obtains the information needed to pay death benefits and annuities due but unpaid at death under the Railroad Retirement Act. Benefits are paid to designated beneficiaries or to survivors in a priority designated by law.

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Authorizing Statute(s): US Code: 45 USC 231(f) et seq 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 8619	02/15/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 25058	04/27/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Application for Survivor Death Benefits	AA-21 (Proposed) Updated 08082025, AA-21 (Proposed), AA-21CERT Completed, AA-21CERT (All Possible), AA-21 (12-18), G-131 (12-18)	Authorization of Payment and Release of All Claims to a Death Benefit or Accrued Annuity Payment ,   Application Summary and Certification ,   Application for Lump-Sum Death Payment and Annuities Unpaid at Death ,   Application Summary and Certification
Funeral Director's Statement of Burial Charges	G-273A (Proposed), G-273a (06-19), G-273A (Proposed) Updated 08082025	Funeral Director's Statement of Burial Expenses ,   Funeral Director's Statement of Burial Expenses

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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	7,800	7,800	0	0	0	0
Annual Time Burden (Hours)	1,975	1,975	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: 08/08/2025

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