Information Collection

Claimant Travel Reimbursement Request

IC 179637 under ICR 200704-0960-011 · OMB 0960-0752.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0752 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-104 Claimant Travel Reimbursement Request	Form
SSA-104 Claimant Travel Reimbursement Request SSA-104.doc	Form

IC Title:

Claimant Travel Reimbursement Request

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.999a-d

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
Form	SSA-104	Claimant Travel Reimbursement Request	SSA-104.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 11,092

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	11,092	11,092
Annual IC Time Burden (Hours)	1,849	1,849
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.