REQUEST FOR WORKER'S COMPENSATION/PUBLIC DISABILITY BENEFIT INFORMATION

ICR 198611-0960-004

OMB: 0960-0098

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0960-0098 198611-0960-004
Historical Active 198401-0960-007
SSA
REQUEST FOR WORKER'S COMPENSATION/PUBLIC DISABILITY BENEFIT INFORMATION
Revision of a currently approved collection   No
Regular
Approved without change 01/15/1987
Retrieve Notice of Action (NOA) 11/26/1986
  Inventory as of this Action Requested Previously Approved
01/31/1990 01/31/1990 02/28/1987
32,500 0 32,500
8,125 0 8,125
0 0 0

THE INFORMATION COLLECTED BY THE USE OF FORM SSA-1709 IS NEEDED TO REQUEST AND/OR VERIFY INFORMATION ABOUT WORKER'S COMPENSATION OR OTHER DISABILITY BENEFITS MADE TO SOCIAL SECURITY DISABILITY INSURANCE BENEFIT BENEFICIARIES SO THAT PROPER ADJUSTMENT I MADE TO THEIR MONTHLY BENEFITS. THE AFFECTED PUBLIC IS COMPRISED OF STATE AND LOCAL GOVERNMENTS AND OR BUSINESSES THAT ADMINISTER WORKER'S

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR WORKER'S COMPENSATION/PUBLIC DISABILITY BENEFIT INFORMATION SSA-1709

  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 32,500 32,500 0 0 0 0
Annual Time Burden (Hours) 8,125 8,125 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.
11/26/1986


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