Information Collection

Ssa-2855

IC 200252 under ICR 201111-0960-013 · OMB 0960-0481.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0481 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-2855 SSA-2855	Form and Instruction
SSA-2855 Statement of Funds You Recieve SSA-2855 - Revised Version.pdf	Form and Instruction
SSA-2855 - Current Version.pdf Current SSA-2855	IC Document

IC Title:

SSA-2855

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 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-2855	Statement of Funds You Recieve	SSA-2855 - 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: 20,000

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	20,000	20,000
Annual IC Time Burden (Hours)	3,333	3,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-2855	SSA-2855 - Current Version.pdf	12/16/2011

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