DOMESTIC SERVICE QUESTIONNAIRE

ICR 197809-0960-002

OMB: 0960-0047

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
114411 Migrated
ICR Details
0960-0047 197809-0960-002
Historical Active 197602-0960-002
SSA
DOMESTIC SERVICE QUESTIONNAIRE
Extension without change of a currently approved collection   No
Regular
Approved without change 09/27/1978
Retrieve Notice of Action (NOA) 09/21/1978
  Inventory as of this Action Requested Previously Approved
09/30/1983 09/30/1983 02/28/1981
20,000 0 20,000
10,000 0 10,000
0 0 0

SECTION 205(A) AND 210(A)(3) OF THE SOCIAL SECURITY ACT PROVIDES FOR THE INFORMATION REQUIRED TO DETERMINE WHETHER A BONA FIDE EMPLOYER- EMPLOYEE RELATIONSHIP EXISTS WITH RESPECT TO DOMESTIC SERVICES. THE FORM IS USED TO DISTINGUISH BETWEEN GENUINE EMPLOYMENT AND COOPERATIVE FAMILY OR DEPENDENCY RELATIONSHIP.

None
None


No

1
IC Title Form No. Form Name
DOMESTIC SERVICE QUESTIONNAIRE SSA-7155-F4

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 20,000 20,000 0 0 0 0
Annual Time Burden (Hours) 10,000 10,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/21/1978


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