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 200608-0960-011 · OMB 0960-0144.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0144 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
i3441-Current.doc s044a90.ssa.gov/apps6z/i3441/ee001gen.jsp	Other-Internet Collection Screen
i3441 Proposed.doc s044a90.ssa.gov/apps6z/i3441/ee001gen.jsp	Other-Internet Collection Screen

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: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internet Collection Screen				https://s044a90.ssa.gov/apps6z/i3441/ee001gen.jsp	Yes	Yes	Fillable Fileable
Other-Internet Collection Screen				https://s044a90.ssa.gov/apps6z/i3441/ee001gen.jsp	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Survivor Compensation

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	Previously Approved
Annual Number of Responses for this IC	1,112,720	1,112,720
Annual IC Time Burden (Hours)	924,967	924,967
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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