Information Collection

Credit Card Payment Form

IC 9686 under ICR 201109-0960-003 · OMB 0960-0648.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0648 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1414 Credit Card Payment Form	Form
SSA-1414 Credit Card Payment Form SSA-1414 (Revised Version).pdf	Form
SSA-1414 (Current Version).pdf Current SSA-1414	IC Document

IC Title:

Credit Card Payment Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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	SSA-1414	Credit Card Payment Form	SSA-1414 (Revised Version).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: 6,000

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	6,000	5,900	100
Annual IC Time Burden (Hours)	200	192	8
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-1414	SSA-1414 (Current Version).pdf	11/30/2011

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