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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.