Information Collection

Agency/Employer Government Pension Offset Questionnaire

IC 9355 under ICR 201004-0960-008 · OMB 0960-0470.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0470 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L4163 Agency/Employer Government Pension Offset Questionnaire	Form and Instruction
SSA-L4163 Agency/Employer Government Pension Offset Questionnaire SSA-L4163 Final.pdf	Form and Instruction
SSA-L4163.pdf SSA-4163 (current version)	IC Document

IC Title:

Agency/Employer Government Pension Offset Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.408(a)

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-L4163	Agency/Employer Government Pension Offset Questionnaire	SSA-L4163 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: 1,000

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-4163 (current version)	SSA-L4163.pdf	08/05/2010

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