Information Collection

Evaluation And Measurement System - Supplemental Security Income Questionnaire

IC 114836 under ICR 197711-0960-004 · OMB 0960-0134.

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Information Collection (IC) Details

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IC Title:	EVALUATION AND MEASUREMENT SYSTEM - SUPPLEMENTAL SECURITY INCOME QUESTIONNAIRE	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA 9750				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,000	-3,000	6,000
Annual IC Time Burden (Hours)	4,500	-4,500	9,000
Annual IC Cost Burden (Dollars)	0	0	0

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Title	Document	Date Uploaded

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