Information Collection

Medicare-only Paper Form SSA-1

IC 191245 under ICR 200911-0960-003 · OMB 0960-0618.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0618 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1 Medicare-only Paper Form SSA-1	Form and Instruction
SSA-1 Application for Retirement Insurance Benefits Paper Form SSA-1 (IC 1).pdf	Form and Instruction

IC Title:

Medicare-only Paper Form SSA-1

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 404.1501-.1512 20 CFR 404.315-.322 20 CFR 404.330-.333 20 CFR 404.601-.603 20 CFR 404.310-.311

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-1	Application for Retirement Insurance Benefits	Paper Form SSA-1 (IC 1).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: 1,000

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	117	117
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.