Information Collection

Disability Report-Appeal 20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 405 subpart C, 422.140

IC 43698 under ICR 200606-0960-005 · OMB 0960-0144.

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Document Name	Document Type

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IC Title:

Disability Report-Appeal 20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 405 subpart C, 422.140

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	SSA-3441-BK	Yes	Yes
Form	EDCS-SSA-3441	Yes	Yes
Form	I3441	Yes	Yes

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,112,720

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 64 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,112,720	-98	1,112,818
Annual IC Time Burden (Hours)	924,967	360,213	564,754
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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