Information Collection

AA-12 Notice of Death and Statement of Compensation

IC 45663 under ICR 202601-3220-001 · OMB 3220-0005.

Documents and Forms

Document Name Document Type
Form AA-12 (01-19) Notice of Death and Request for Service Needed for Eligibility AA-12 Notice of Death and Statement of Compensation Form
AA-12 (01-19) Notice of Death and Request for Service Needed for Eligi Form AA-12 (01-19).pdf www.rrb.gov/sites/default/files/2019-01/AA-12%20(01-19).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	AA-12 Notice of Death and Statement of Compensation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 209.6

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	AA-12 (01-19)	Notice of Death and Request for Service Needed for Eligibility	Form AA-12 (01-19).pdf	https://www.rrb.gov/sites/default/files/2019-01/AA-12%20(01-19).pdf	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: Survivor Compensation

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

Number of Respondents: 579	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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

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