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60-Day Notice of Proposed Information Collection: Statement of Claim Related to Pensions Provided by the Kingdom of Belgium

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Notice of request for public comment.


The Department of State is seeking Office of Management and Budget (OMB) approval for the information collection described below. In accordance with the Paperwork Reduction Act of 1995, we are requesting comments on this collection from all interested individuals and organizations. The purpose of this notice is to allow 60 days for public comment preceding submission of the collection to OMB.


The Department will accept comments from the public up to October 3, 2016.


You may submit comments by any of the following methods:

  • Web: Persons with access to the Internet may comment on this notice by going to You can search for the document by entering “Docket Number: DOS-2016-0055” in the Search field. Then click the “Comment Now” button and complete the comment form.
  • Email:
  • Regular Mail: Send written comments to: Office of the Assistant Legal Adviser for Management, ATTN: Belgium Claim Form, Room 4325, 2201 C Street NW., Washington, DC 20520.

You must include the DS form number (if applicable), information collection title, and the OMB control number in any correspondence.

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Direct requests for additional information regarding the collection listed in this notice, including requests for copies of the proposed collection instrument and supporting documents, to Alice Kottmyer, Office of the Legal Adviser for Management, who may be reached on 202-647-2318 or

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  • Title of Information Collection: Statement of Claim Related to Pensions Provided by the Kingdom of Belgium.
  • OMB Control Number: None.
  • Type of Request: New Collection.
  • Originating Office: Office of the Legal Adviser.
  • Form Number: DS-7792.
  • Respondents: Individuals who earned a pension from the Government of Belgium for work in one of its overseas territories.Start Printed Page 51537
  • Estimated Number of Respondents: 20.
  • Estimated Number of Responses: 20.
  • Average Time per Response: 30 minutes.
  • Total Estimated Burden Time: 10 hours.
  • Frequency: Once per respondent.
  • Obligation to Respond: Required to obtain a benefit.

We are soliciting public comments to permit the Department to:

  • Evaluate whether the proposed information collection is necessary for the proper functions of the Department.
  • Evaluate the accuracy of our estimate of the time and cost burden for this proposed collection, including the validity of the methodology and assumptions used.
  • Enhance the quality, utility, and clarity of the information to be collected.
  • Minimize the reporting burden on those who are to respond, including the use of automated collection techniques or other forms of information technology.

Please note that comments submitted in response to this Notice are public record. Before including any detailed personal information, you should be aware that your comments as submitted, including your personal information, will be available for public review.

Abstract of proposed collection: This collection will implement the 1982 Agreement Between the Government of the United States of America and the Kingdom of Belgium on Social Security, and related agreements. This information collection will facilitate compensation for eligible claimants in situations where the pension provided by the Government of Belgium needs to be supplemented.

Methodology: The information will be collected on a form, the DS-7792, Statement of Claim, which can be submitted by mail, email, or fax.

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Dated: July 29, 2016.

Lisa J. Grosh,

Assistant Legal Adviser, International Claims and Investment Disputes.

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[FR Doc. 2016-18529 Filed 8-3-16; 8:45 am]