Information Collection

State/Local/Tribal Government: Paper SSA-11-BK

IC 186313 under ICR 200808-0960-009 · OMB 0960-0014.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0014 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-11-BK State/Local/Tribal Government: Paper SSA-11-BK	Form
SSA-11-BK Request to be Selected as Payee SSA-11-BK Mock-Up of Revisions--New Privacy Act Statements.pdf	Form

IC Title:

State/Local/Tribal Government: Paper SSA-11-BK

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.2010-404.2055 20 CFR 416.601-416.665

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-11-BK	Request to be Selected as Payee	SSA-11-BK Mock-Up of Revisions--New Privacy Act Statements.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: 5,000

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	5,000	5,000
Annual IC Time Burden (Hours)	875	875
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.