Statemernt of Employer 20 CFR, 404.801-803

ICR 200606-0960-001

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
43689 Migrated
ICR Details
0960-0030 200606-0960-001
Historical Active 200305-0960-006
SSA
Statemernt of Employer 20 CFR, 404.801-803
Revision of a currently approved collection   No
Regular
Approved without change 08/07/2006
Retrieve Notice of Action (NOA) 06/02/2006
  Inventory as of this Action Requested Previously Approved
08/31/2009 36 Months From Approved 08/31/2006
925,000 0 925,000
308,333 0 308,333
0 0 0

The information collected on the form is needed to substantiate allegations of wages paid to workers when wages do not appear in SSA's records of earnings and the worker has no proof of siad earnings. SSA can use the information to process claims for benefits and resolve discrepancies in the worker's earnings record. The respondents are certain employers who can verify wage allegations made by the wage earner.

None
None


No

1
IC Title Form No. Form Name
Statemernt of Employer 20 CFR, 404.801-803 SSA-7011-F4

  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.
06/02/2006


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