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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.