Information Collection

Request for Administrative Information

IC 183366 under ICR 200801-0960-001 · OMB 0960-0646.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0646 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5666 Request for Administrative Information	Form and Instruction
SSA-5666 Request for Administrative Information SSA-5666-BK Mock-up.pdf	Form and Instruction
SSA-5666-BK Original.pdf SSA-5666-BK	IC Document

IC Title:

Request for Administrative Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.924a 20 CFR 404.1520

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 and Instruction	SSA-5666	Request for Administrative Information	SSA-5666-BK Mock-up.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 615,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	615,000	615,000
Annual IC Time Burden (Hours)	153,750	153,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-5666-BK	SSA-5666-BK Original.pdf	01/11/2008

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