Information Collection

Ssa-l9784

IC 195824 under ICR 201012-0960-005 · OMB 0960-0369.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0369 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L9784 SSA-L9784	Form and Instruction
SSA-L9784 Retirement, Survivors and Disability Insurance: Earnings SSA-L9784-SM - Revised Version.pdf	Form and Instruction
SSA-L9784-SM.pdf Curent Version of the SSA-L9784	IC Document

IC Title:

SSA-L9784

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.452-404.455

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-L9784	Retirement, Survivors and Disability Insurance: Earnings Estimate Form	SSA-L9784-SM - Revised Version.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: 1,270

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
Annual Number of Responses for this IC	1,270	1,270
Annual IC Time Burden (Hours)	212	212
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Curent Version of the SSA-L9784	SSA-L9784-SM.pdf	03/07/2011

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