Information Collection

Modified Benefit Formula Questionnaire

IC 9252 under ICR 201010-0960-002 · OMB 0960-0395.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0395 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-150 Modified Benefit Formula Questionnaire Form
SSA-150 Modified Benefit Formula Questionnaire SSA-150 - Revised.pdf Form
SSA-150 (MCS Scree Modified Benefit Formula Questionnaire SSA-150 MCS Screens.pdf Form
SSA-150 - Current.pdf Current SSA-150 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Modified Benefit Formula Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-150	Modified Benefit Formula Questionnaire	SSA-150 - Revised.pdf		No		Paper Only
Form	SSA-150 (MCS Screens)	Modified Benefit Formula Questionnaire	SSA-150 MCS Screens.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 90,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Previously Approved
Annual Number of Responses for this IC	90,000	90,000
Annual IC Time Burden (Hours)	12,000	12,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-150	SSA-150 - Current.pdf	10/22/2010

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