Information Collection

SSA-5665-BK (electronic)

IC 197497 under ICR 201103-0960-016 · OMB 0960-0646.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0646 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5665-BK (Elect SSA-5665-BK (electronic)	Form and Instruction
ODAR Cover Letter (SSA-5665 Teacher Questionnaire) (2)(Final) (2).docx	Other-Cover Letter
SSA-5665-BK (Elect Teacher Questionnaire SSA-5665(Revised).pdf	Form and Instruction
SSA-5665[current form).pdf SSA-5665(current)	IC Document

IC Title:

SSA-5665-BK (electronic)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.1103(f)

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-5665-BK (Electronic)	Teacher Questionnaire	SSA-5665(Revised).pdf		Yes	Yes	Fillable Fileable Signable
Other-Cover Letter			ODAR Cover Letter (SSA-5665 Teacher Questionnaire) (2)(Final) (2).docx		Yes	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 388,581

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 97 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	388,581	388,581
Annual IC Time Burden (Hours)	259,054	259,054
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-5665(current)	SSA-5665[current form).pdf	05/12/2011

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