Information Collection

Request For Employment Information In Connection With Claim For Disability Benefits (income Information)

IC 146830 under ICR 197610-2900-002 · OMB 2900-0065.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2900-0065 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

REQUEST FOR EMPLOYMENT INFORMATION IN CONNECTION WITH CLAIM FOR DISABILITY BENEFITS (INCOME INFORMATION)

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	21-4192				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 65,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	65,000	65,000
Annual IC Time Burden (Hours)	16,250	16,250
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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