Information Collection

SSA-827 (with electronic signature(adult first person only)

IC 197969 under ICR 201106-0960-004 · OMB 0960-0623.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0623 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
eAuthorization EDCS screen shots 062011.pdf	Other-Internal Screens
i3368 screenshots.pdf www.socialsecurity.com	Other-Internet Screens
i3441 screenshots.pdf www.socialsecurity.com	Other-Internet Screens
PA Statement for SSA-827.pdf	Other-Internal Screens

IC Title:

SSA-827 (with electronic signature(adult first person only)

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 404.1512 20 CFR 416.912 45 CFR 160 & 164

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internal Screens	eAuthorization EDCS screen shots 062011.pdf		Yes	Yes	Fillable Fileable Signable
Other-Internet Screens	i3368 screenshots.pdf	www.socialsecurity.com	Yes	Yes	Fillable Fileable Signable
Other-Internet Screens	i3441 screenshots.pdf	www.socialsecurity.com	Yes	Yes	Fillable Fileable Signable
Other-Internal Screens	PA Statement for SSA-827.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,530,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,530,000	2,530,000
Annual IC Time Burden (Hours)	379,500	379,500
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.