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Submission for OMB Review; Comment Request for the Review of a Revised Information Collection: SF 2809

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Office of Personnel Management.




In accordance with the Paperwork Reduction Act of 1995 (Pub. L. 104-13, May 22, 1995), this notice announces that the Office of Personnel Management (OPM) has submitted to the Office of Management and Budget (OMB) a request for the review of a revised information collection. SF 2809, Health Benefits Election Form, is used by Federal employees, annuitants other than those under the Civil Service Retirement System (CSRS) and the Federal Employees Retirement System (FERS) [including individuals receiving benefits from the Office of Workers' Compensation Programs], former spouses eligible for benefits under the Spouse Equity Act of 1984, and separated employees and former dependents eligible to enroll under the Temporary Continuation of Coverage provisions of the FEHB law (5 U.S.C. 8905a). A different form (OPM 2809) is used by CSRS and FERS annuitants whose health benefit enrollments are administered by OPM's Retirement Services Program.

Approximately 18,000 SF 2809 forms are completed annually. Each form takes approximately 30 minutes to complete. The annual estimated burden is 9,000 hours.

For copies of this proposal, contact Mary Beth Smith-Toomey on (202) 606-8358, or e-mail to Please include your mailing address with your request. This proposal is not available electronically.


Comments on this proposal should be received within 30 calendar days from the date of this publication.


Send or deliver comments to—Frank D. Titus, Assistant Director, Insurance Services Program, Center for Retirement & Insurance Services, U.S. Office of Personnel Management, 1900 E Street, NW., Room 3400, Washington, DC 20415; and Joseph F. Lackey, OPM Desk Officer, Office of Information and Regulatory Affairs, New Executive Office Building, NW., Room 10235, Washington, DC 20503.

For Information Regarding Administrative Coordination—Contact:

Cyrus S. Benson, Team Leader, RIS Support Services/Support Group, Publications Team, (202) 606-0623.

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Office of Personnel Management.

Kay Coles James,


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[FR Doc. 04-15133 Filed 7-2-04; 8:45 am]