Information Collection

Ssa-9301

IC 9763 under ICR 201108-0960-003 · OMB 0960-0707.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0707 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SSA-9301 Revised Version.docx	Other-Telephone Interview Script
SSA-9301 Current Version.docx Current version of SSA-9301	IC Document

IC Title:

SSA-9301

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 418(b)(5) (To search for a specific CFR, visit the Code of Federal Regulations.)

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
Other-Telephone Interview Script				N/A conducted over telephone	No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	2,500	2,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current version of SSA-9301		08/29/2011

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].