Statement of Employer, 20 CFR 404.801 - .803

ICR 200305-0960-006

OMB: 0960-0030

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
8929 Migrated
ICR Details
0960-0030 200305-0960-006
Historical Active 200004-0960-001
SSA
Statement of Employer, 20 CFR 404.801 - .803
Extension without change of a currently approved collection   No
Regular
Approved without change 07/25/2003
Retrieve Notice of Action (NOA) 05/27/2003
  Inventory as of this Action Requested Previously Approved
07/31/2006 07/31/2006 07/31/2003
925,000 0 925,000
308,333 0 308,333
0 0 0

The information collected on Form SSA-7011 is needed by SSA to substantiate allegations of wages paid to workers when those wages do not appear on the SSA earnings record and the worker does not have proof that payment was made. This information is used to process claims for Social Security benefits and to resolve discrepancies in earnings records. The respondents are certain employers who can verify allegations of wages made by the wage earner.

None
None


No

1
IC Title Form No. Form Name
Statement of Employer, 20 CFR 404.801 - .803 SSA-7011-BK

  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 925,000 925,000 0 0 0 0
Annual Time Burden (Hours) 308,333 308,333 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.
05/27/2003


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