Claim for Death Benefits

ICR 201605-1121-001

OMB: 1121-0024

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2016-05-19
IC Document Collections
IC ID
Document
Title
Status
12363 Modified
ICR Details
1121-0024 201605-1121-001
Historical Active 200404-1121-001
DOJ/OJP BJA
Claim for Death Benefits
Reinstatement without change of a previously approved collection   No
Regular
Approved without change 08/18/2016
Retrieve Notice of Action (NOA) 05/25/2016
  Inventory as of this Action Requested Previously Approved
08/31/2019 36 Months From Approved
350 0 0
700 0 0
3,281 0 0

The Public Safety Officers Benefits (PSOB) Program provides a one-time benefit of $250,000 to the eligible survivors of local, state and federal public safety officers whose deaths result from traumatic injuries substained in the line of duty. The agency requires the information requested on this form to identify survivors and determine their eligibility for the Public Safety Officer Death Benefit in accordance with the statutory requirements found in 42 USC Sec. 3796. Respondents include surviving spouses, children and/or parents of deceased public safety officers.

US Code: 42 USC 3796 Name of Law: The Public Safety Officers Benefits
  
None

Not associated with rulemaking

  81 FR 1224 01/11/2016
81 FR 19240 04/04/2016
No

1
IC Title Form No. Form Name
Claim for Death Benefits 3650/5 Claim for Death Benefits

  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 350 0 0 30 0 320
Annual Time Burden (Hours) 700 0 0 220 0 480
Annual Cost Burden (Dollars) 3,281 0 0 281 0 3,000
Yes
Miscellaneous Actions
No
The number of respondents increased slightly.

$28,275
No
No
No
No
No
Uncollected
Hope Janke 202 514-6278 askpsob@usdoj.gov

  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.
05/25/2016


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