Self-Employment/Corporate Officer Questionnaire

ICR 200307-0960-005

OMB: 0960-0487

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
9384 Migrated
ICR Details
0960-0487 200307-0960-005
Historical Active 200207-0960-004
SSA
Self-Employment/Corporate Officer Questionnaire
Extension without change of a currently approved collection   No
Regular
Approved without change 09/12/2003
Retrieve Notice of Action (NOA) 07/25/2003
  Inventory as of this Action Requested Previously Approved
09/30/2006 09/30/2006 09/30/2003
50,000 0 50,000
16,667 0 16,667
0 0 0

Form SSA-4184 is used to develop earnings data and corroborate the claimant's allegations of retirement when the claimant is self-employed or a corporate officer. The information collected is used to determine benefit amounts. The respondents are self-employed individuals and corporate officers.

None
None


No

1
IC Title Form No. Form Name
Self-Employment/Corporate Officer Questionnaire SSA-4184

  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 50,000 50,000 0 0 0 0
Annual Time Burden (Hours) 16,667 16,667 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.
07/25/2003


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