Information Collection

Quarterly Work Incentive Demonstration Program Report

IC 115128 under ICR 198311-0960-008 · OMB 0960-0254.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0254 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	QUARTERLY WORK INCENTIVE DEMONSTRATION PROGRAM REPORT	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4769				No	No
Form	(9-81)				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,958	2,878	80
Annual IC Time Burden (Hours)	1,613	413	1,200
Annual IC Cost Burden (Dollars)	0	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.