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Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants
Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants
OMB: 3206-0202
IC ID: 33692
OMB.report
OPM
OMB 3206-0202
ICR 201108-3206-002
IC 33692
( )
Documents and Forms
Document Name
Document Type
Form DPRS 2809
Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants
Form and Instruction
DPRS 2809 Request to Change FEHB or to Receive Plan Brochures for
DPRS 2809.pdf
Form and Instruction
2008 Markups.pdf
2008 Markups
IC Document
2011 Markups.pdf
2011 Markups
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Request to Change FEHB Enrollment or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitants
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
DPRS 2809
Request to Change FEHB or to Receive Plan Brochures for Spouse Equity/Temporary Continuation of Coverage Enrollees/Direct Pay Annuitant
DPRS 2809.pdf
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
General Government
Subfunction:
Executive Functions
Privacy Act System of Records
Title:
OPM/Central-1
FR Citation:
73 FR 15013
Number of Respondents:
27,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
27,000
0
0
0
0
27,000
Annual IC Time Burden (Hours)
20,250
0
0
0
0
20,250
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
2008 Markups
2008 Markups.pdf
08/18/2011
2011 Markups
2011 Markups.pdf
08/18/2011
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.