Information Collection

Statement Of Institution Or Social Agency

IC 114570 under ICR 197504-0960-004 · OMB 0960-0083.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0083 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	STATEMENT OF INSTITUTION OR SOCIAL AGENCY	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-1255				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,500	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	8,333	8,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.