Ri 94-7 Ss

OMB SUPPORTING STATEMENT

RI 94-7 – Death Benefit Payment Rollover Election Form

1. Justification

1. The Unemployment Compensation Amendments of 1992 (UCA), Public Law No. 102-318, and Income Tax Regulations under sections 401(a)(31), 402(c), 402(f) and 3405(c) of the Internal Revenue Code of 1986, require guidance concerning the direct rollover and 20-percent income tax withholding provisions of UCA. The RI 94-7 provides FERS surviving spouses and surviving former spouses with the means to elect payment of FERS rollover-eligible benefits directly or to an Individual Retirement Arrangement (IRA), eligible employer plan or Thrift Savings Plan (TSP) account.

2. OPM employees will use the information provided by the survivor to pay benefits to an

IRA, employer plan or TSP account or to deduct 20 percent from the payments sent directly to the surviving spouse or former spouse for Federal income tax withholding.

3. There is no other method for receiving this information from the survivor.

4. There is no duplication of this information through the use of any other form or process.

5. This collection of information does not impact small businesses or other small entities.

6. If this information is not collected, survivors of deceased Federal employees/retirees would not have the option to roll lump sum benefits over into an IRA.

7. This collection is consistent with the guidelines in 5 CFR 1320.6.

8. A notice of proposed information collection was published in the Federal Register, on

June 11, 2010, giving persons outside the agency an opportunity to comment. No comments were received.

9. No gift or payment is awarded respondents based on return of the form.

10. This information collection is protected by the Privacy Act of 1974 and OPM regulations (5 CFR 841.108). The routine uses of disclosure appear in the Federal Register for OPM/Central-1 (73 FR 15013, et. seq., March 20, 2008).

11. This information collection does not include questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.

12. Approximately 3444 forms are mailed annually. The form takes approximately 1 hour to complete. An annual burden of 3444 hours is estimated.

13. There is no cost to the respondent.

14. The annualized cost to the government is $155,021. This cost includes employee salary hours devoted to this program, forms, and overhead.

15. The annual burden has not changed.

16. The results of this information collection are not published.

17. It is not cost-effective to reprint the whole supply of forms to change the OMB clearance expiration date. Therefore, we seek approval not to display the date on the form.

18. There are no exceptions to the certification statement.