Credit Card Payment Acknowledgement Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0648 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-1414 Credit Card Payment Acknowledgement Form Form
SSA-1414 Credit Card Payment Acknowledgement Form SSA-1414.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Credit Card Payment Acknowledgement Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-1414	Credit Card Payment Acknowledgement Form	SSA-1414.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: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.