Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form RI120-126 Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84	Form and Instruction	Modified	Available
Form RI120-126 Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84	Form and Instruction	Modified	Repair queued
RI20-126_OMBSupportingStmt_2025.docx	Supporting Statement A	Uploaded 2025-11-28	Repair queued
RI20-126_OMBSupportingStmt_2025.docx	Supporting Statement A	Uploaded 2025-11-28	Repair queued
E8-5659.pdf	Supplementary Document	Uploaded 2019-06-07	Available
E8-5659.pdf	Supplementary Document	Uploaded 2019-06-07	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
218495	Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84	Form and Instruction	Modified	Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84
218495	Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84	Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0268	ICR Reference No: 202511-3206-005
Status: Active	Previous ICR Reference No: 202211-3206-002
Agency/Subagency: OPM	Agency Tracking No: RI 20-126
Title: Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/26/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/28/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2029	36 Months From Approved	02/28/2026
Responses	1,000	0	1,000
Time Burden (Hours)	500	0	500
Cost Burden (Dollars)	18,010	0	13,437

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Abstract: RI 20-126 is used to certify that an employee performed certain service with the District of Columbia (DC) that qualifies under section 1905 of PL 111-84 for determining retirement eligibility. However, this service cannot be used in the computation of a retirement benefit.

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Authorizing Statute(s): PL: Pub.L. 111 - 84 1905 Name of Law: Certification of Qualifying DC Service Under Public Law 111-84 Sec 1905
  

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:
	90 FR 23383	06/02/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 54409	11/26/2025
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
Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84	RI120-126	Certification of Qualifying District of Columbia Service Under Section 1905 of Public Law 111-84

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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	1,000	1,000	0	0	0	0
Annual Time Burden (Hours)	500	500	0	0	0	0
Annual Cost Burden (Dollars)	18,010	13,437	0	4,573	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: $5,550

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: 11/28/2025

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