Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms")

Clearance of Information Collections Conducted by State Disability Determination Services on Behalf of SSA

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0555 can be found here:

Documents and Forms

Document Name Document Type
Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms") Form and Instruction
Sample CE Forms CE Credentials Letter Revised.pdf Form and Instruction
CE Samples current version.pdf CE Credentials Current Version IC Document

Information Collection (IC) Details

IC Title:	Category I, CE a) Source Credentialing Information (Subset of "CE Sample Forms")	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1519 20 CFR 416.919

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	N/A	Sample CE Forms	CE Credentials Letter 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: 3,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	750	750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CE Credentials Current Version	CE Samples current version.pdf	05/19/2011

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