Information Collection

SSA-L2765, Request for Self-Employment Information

IC 9413 under ICR 201004-0960-004 · OMB 0960-0508.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0508 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L2765 Request for Self-Employment Information SSA-L2765, Request for Self-Employment Information	Form
SSA-L2765 Request for Self-Employment Information Revised SSA-L2765 (for use in 2010).pdf	Form
Current SSA-L2765 (2009).pdf Current SSA-L2765	IC Document

IC Title:

SSA-L2765, Request for Self-Employment Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 422.120

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-L2765	Request for Self-Employment Information	Revised SSA-L2765 (for use in 2010).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: 7,870

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	Previously Approved
Annual Number of Responses for this IC	7,870	-7,530	15,400
Annual IC Time Burden (Hours)	1,312	-1,255	2,567
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-L2765	Current SSA-L2765 (2009).pdf	07/09/2010

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