Information Collection

Modified Benefit Formula Questionnaire-Employer

IC 9371 under ICR 201011-0960-003 · OMB 0960-0477.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0477 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-58 Modified Benefit Formula Questionnaire-Employer	Form
SSA-58 Modified Benefit Formula Questionnaire-Employer SDOC0001 (revised).pdf	Form

IC Title:

Modified Benefit Formula Questionnaire-Employer

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1512-404.1515 20 CFR 416.912-416.915

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-58	Modified Benefit Formula Questionnaire-Employer	SDOC0001 (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: 30,000

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	30,000	30,000
Annual IC Time Burden (Hours)	10,000	10,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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