Information Collection

f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398

IC 184462 under ICR 200907-0960-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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-1391 f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction
SSA-1391 Employment Network Payment Request Form SSA-1391.pdf	Form and Instruction
SSA-1389 EN Services Certification Statement (For Use with Phase SSA-1389.pdf	Form and Instruction
SSA-1393 Employment Network Supplemental Earnings Statement SSA-1393.pdf	Form and Instruction
SSA-1399 Auto Pay Request Form SSA-1399.pdf	Form and Instruction
SSA-1396 Earnings Inquiry Request Form SSA-1396.pdf	Form and Instruction
SSA-1398 Self-Employment Income (SEI) Form Beneficiary Quarterly SSA-1398.pdf	Form and Instruction

IC Title:

f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 411.575

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-1391	Employment Network Payment Request Form	SSA-1391.pdf	No		Paper Only
Form and Instruction	SSA-1389	EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request)	SSA-1389.pdf	No		Paper Only
Form and Instruction	SSA-1393	Employment Network Supplemental Earnings Statement	SSA-1393.pdf	No		Printable Only
Form and Instruction	SSA-1399	Auto Pay Request Form	SSA-1399.pdf	Yes	No	Printable Only
Form and Instruction	SSA-1396	Earnings Inquiry Request Form	SSA-1396.pdf	Yes	No	Printable Only
Form and Instruction	SSA-1398	Self-Employment Income (SEI) Form Beneficiary Quarterly Report Self-Employment	SSA-1398.pdf	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 12,420

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,420	0	12,420
Annual IC Time Burden (Hours)	6,210	-6,210	12,420
Annual IC Cost Burden (Dollars)	0	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.