Information Collection

411.140(d)(3); 411.385(a); 411.390 -- SSA-1365

IC 184502 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⚠️ Notice: This information collection may be referencing outdated material.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-1365 411.140(d)(3); 411.385(a); 411.390 -- SSA-1365	Form
SSA-1365 State Agency Ticket Assignment Form Ticket to Work and S Revised SSA-1365.pdf	Form

IC Title:

411.140(d)(3); 411.385(a); 411.390 -- SSA-1365

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 411.140(d)(3) 20 CFR 411.385(a)

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-1365	State Agency Ticket Assignment Form Ticket to Work and Self-Sufficiency Program	Revised SSA-1365.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: 25,174

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	25,174	25,174
Annual IC Time Burden (Hours)	1,259	1,259
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.