Information Collection

20 CFR 411.200(b)--SSA-1375 (Beneficiaries)

IC 184457 under ICR 200804-0960-005 · OMB 0960-0644.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0644 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1375 20 CFR 411.200(b)--SSA-1375 (Beneficiaries)	Form
SSA-L1373.pdf	Instruction
SSA-L1374.pdf	Instruction
SSA-1375 Ticket to Work Progress Review Form SSA-1375.pdf	Form

IC Title:

20 CFR 411.200(b)--SSA-1375 (Beneficiaries)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 411.200(b)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-1375	Ticket to Work Progress Review Form	SSA-1375.pdf	No	Paper Only
Instruction			SSA-L1373.pdf	No	Paper Only
Instruction			SSA-L1374.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: 13,500

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	13,500	13,500
Annual IC Time Burden (Hours)	3,375	3,375
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.