Information Collection

Request for Accommodation in Communication Method (paper form)

IC 192017 under ICR 201006-0960-003 · OMB 0960-0777.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0777 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-9000 Request for Accommodation in Communication Method (paper form)	Form and Instruction
SSA-9000 Request for Accommodation in Communication Method SSA-9000 (F).pdf	Form and Instruction
Form SSA-9000 (0960-0777).doc SSA-9000 - Old Version	IC Document

IC Title:

Request for Accommodation in Communication Method (paper form)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 85.51

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-9000	Request for Accommodation in Communication Method	SSA-9000 (F).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: 250

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	250	-250	500
Annual IC Time Burden (Hours)	63	-62	125
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-9000 - Old Version	Form SSA-9000 (0960-0777).doc	07/26/2010

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