Information Collection

Claimant Travel Reimbursement Request

IC 179637 under ICR 201002-0960-013 · OMB 0960-0752.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-104 Claimant Travel Reimbursement Request	Form
SSA-104 Claimant Travel Reimbursement Request SSA-104 (revised).pdf	Form
SSA-104 (current).pdf Claimant Travel Reimbursement Request (current)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.999a-d

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	SSA-104	Claimant Travel Reimbursement Request	SSA-104 (revised).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: 11,092

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	Previously Approved
Annual Number of Responses for this IC	11,092	11,092
Annual IC Time Burden (Hours)	1,849	1,849
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Claimant Travel Reimbursement Request (current)	SSA-104 (current).pdf	05/18/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.