View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 3206-0275	ICR Reference No: 202008-3206-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: OPM	Agency Tracking No: SF 3119
Title: Application for Court-Ordered Benefits for Former Spouses, Standard Form 3119
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/09/2020
	Date Received in OIRA: 10/06/2020
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2023	36 Months From Approved
Responses	19,000	0	0
Time Burden (Hours)	9,500	0	0
Cost Burden (Dollars)	255,229	0	0

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	19,000	19,000
Annual Time Burden (Hours)	9,500	9,500
Annual Cost Burden (Dollars)	255,229	255,229

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Calculation for Cost Burden

Annual Cost to Federal Government: $14,590

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. 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? No

Agency Contact: Charles Conyers 202 606-0125 charles.conyers@opm.gov

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