Information Collection

Report on Individual with Mental Impairment--State DDSs

IC 186032 under ICR 201107-0960-005 · OMB 0960-0058.

Documents and Forms

Document Name Document Type
Form SSA-824 Report on Individual with Mental Impairment--State DDSs Form
SSA-824 Report on Individual with Mental Impairment SSA-824.pdf Form
SSA-824 Current Version.pdf Current Version of SSA-824 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Report on Individual with Mental Impairment--State DDSs	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 404.1513 20 CFR 416.913

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-824	Report on Individual with Mental Impairment	SSA-824.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: 250	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	250	-24,750	25,000
Annual IC Time Burden (Hours)	150	-14,850	15,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current Version of SSA-824	SSA-824 Current Version.pdf	08/22/2011

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