Application for Survivor Death Benefits

Forms and Documents

Document Name	Status
Form AA-21 (11-08) Application for Survivor Death Benefits Form and Instruction	Modified
Form G-273a (06-06) Funeral Director's Statement of Burial Charges Form and Instruction	Modified
3220-0031.doc Supporting Statement A	2015-09-30
RB-21.pdf Supplementary Document	2009-05-26

IC Document Collections

IC ID	Document Title	Status
33838	Application for Survivor Death Benefits Form and Instruction	Modified
189282	Funeral Director's Statement of Burial Charges Form and Instruction	Modified

ICR Details

OMB Control No: 3220-0031	ICR Reference No: 201509-3220-004
Status: Historical Active	Previous ICR Reference No: 201207-3220-002
Agency/Subagency: RRB	Agency Tracking No:
Title: Application for Survivor Death Benefits
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: 03/30/2016
	Date Received in OIRA: 09/30/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	36 Months From Approved	03/31/2016
Responses	7,800	0	10,500
Time Burden (Hours)	1,975	0	2,600
Cost Burden (Dollars)	0	0	0

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Abstract: The collection obtains the information needed to pay death benefits and annuities due but unpaid at death under the Railroad Retirement Act. Benefits are paid to designated beneficiaries or to survivors in a priority designated by law.

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Authorizing Statute(s): US Code: 45 USC 231(f) et seq Name of Law: Railroad Retirement Act
  

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:
	80 FR 44402	07/27/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 58526	09/29/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Application for Survivor Death Benefits	AA-21CERT, AA-21 (11-08), AA-11a (09-03), G-131 , AA-21, AA-11a, G-131	Application for Lump-Sum Death Payments and Annuities Unpaid at Death ,   Authorization of Payment and Release of All Claims to a Death Benefit or Accrued Annuity Payment ,   Designation or Change of Beneficiary for Employees with Service Prior to January 1, 1975, for Residual Lump Sum ,   Application Summary and Certification ,   Application for Lump-Sum Death Payments and Annuities Unpaid at Death ,   Designation or Change of Beneficiary for Employees with Service Prior to January 1, 1975 for Residual Lump Sum ,   Authorization of Payment and Release of All Claims to a Death Benefit or Accrued Annuity Payment
Funeral Director's Statement of Burial Charges	G-273a (06-06), G-273a	Funeral Director's Statement of Burial Charges ,   Funeral Director's Statement of Burial Charges

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ICR Summary 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	7,800	10,500	0	0	-2,700	0
Annual Time Burden (Hours)	1,975	2,600	0	0	-625	0
Annual Cost Burden (Dollars)	0	0	0	0	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: The Residual Lump Sum benefit will phase out over time as the population that is eligible to receive a benefit using these forms is diminishing. We have reduced the estimated number of responses for the AA 21cert from 4,500 to 3,500 (-1,000) and the burden hours from 1,500 to 1,167 (-333). We have reduced the estimated number of responses for the AA-21 from 300 to 200 (-100) and the total burden hours from 200 to 133 (-67). We have reduced the estimated number of responses for the G-131 from 600 to 100 (-500) and the total burden hours from 50 to 8 (-42). Lastly, we propose to remove the 100 responses and 17 burden hours for the A-11a from the information collection due to less than 10 responses per year Overall, we have reduced the total number of responses from 10,500 to 7,800 (-2,700) and the total burden hours from 2,600 to 1,975 (-625). We have shown the decrease in responses and the corresponding decrease in burden hours as an adjustment.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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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: 09/30/2015

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