Information Collection

Important Information About Your Appeal, Waiver Rights, and Repayment Options (Paper Form)

IC 191893 under ICR 200910-0960-008 · OMB 0960-0779.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0779 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3105 Important Information About Your Appeal, Waiver Rights, and Repayment Options (Paper Form)	Form and Instruction
SSA-3105 Important Information About Your Appeal, Waiver Rights, SSA-3105 Final.pdf	Form and Instruction

IC Title:

Important Information About Your Appeal, Waiver Rights, and Repayment Options (Paper Form)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.502 - 404.521

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 and Instruction	SSA-3105	Important Information About Your Appeal, Waiver Rights, and Repayment Options	SSA-3105 Final.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: 600,000

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	600,000	600,000
Annual IC Time Burden (Hours)	150,000	150,000
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.