REPORT TO SOCIAL SECURITY ADMINISTRATION ABOUT WORKERS' COMPENSATION

ICR 198402-0960-002

OMB: 0960-0367

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0960-0367 198402-0960-002
Historical Active
SSA
REPORT TO SOCIAL SECURITY ADMINISTRATION ABOUT WORKERS' COMPENSATION
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 04/02/1984
Retrieve Notice of Action (NOA) 02/15/1984
  Inventory as of this Action Requested Previously Approved
02/28/1987 02/28/1987
60,000 0 0
2,000 0 0
0 0 0

THE INFORMATION COLLECTED ON THE FORM SSA-4679 FROM BENEFICIARIES IS NEEDED TO DETERMINE THE AMOUNT OF THEIR WORKERS' COMPENSATION, IF ANY. THE AMOUNTS REPORTED WILL BE USED IN ADJUSTING THE MONTHLY PAYMENTS TO THE BENEFICIARIES WHERE APPROPRIATE.

None
None


No

1
IC Title Form No. Form Name
REPORT TO SOCIAL SECURITY ADMINISTRATION ABOUT WORKERS' COMPENSATION SSA-4679-SM

  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 60,000 0 0 60,000 0 0
Annual Time Burden (Hours) 2,000 0 0 2,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
02/15/1984


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