Annuitant/OWCP Health Benefits Election Form

ICR 200207-3206-002

OMB: 3206-0239

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
33760 Migrated
ICR Details
3206-0239 200207-3206-002
Historical Active 199901-3206-003
OPM
Annuitant/OWCP Health Benefits Election Form
Extension without change of a currently approved collection   No
Regular
Approved without change 08/30/2002
Retrieve Notice of Action (NOA) 07/03/2002
Approved for two years. In its next submission, OPM shall either consolidate this form with 3206-0160 or provide a justification as to why consolidation is not appropriate.
  Inventory as of this Action Requested Previously Approved
09/30/2004 09/30/2004 09/30/2002
9,000 0 9,000
4,500 0 4,500
0 0 0

The SF 2809-1 will be used by annuitants of Federal retirement systems other than the Civil Service Retirement System (CSRS) and the Federal Employees Retirement System (FERS), including the Foreign Service Retirement System and the Office of Workers' Compensation Programs (OWCP) and certain former dependents of these individuals. These include former spouses who are eligible for enrollment under the Spouse Equity Act of 1984 (P.L. 98-615) and certain former dependents who are eligible for enrollment under the Temporary Continuation of Coverage (TCC) provisions of Federal Employees Health Benefits (FEHB) law....

None
None


No

1
IC Title Form No. Form Name
Annuitant/OWCP Health Benefits Election Form SF-2809-1

  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 9,000 9,000 0 0 0 0
Annual Time Burden (Hours) 4,500 4,500 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
07/03/2002


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