Information Collection

SSA-1372-BK (Domestic)--State/Local/Tribal Government

IC 182786 under ICR 201111-0960-015 · OMB 0960-0105.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0105 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1372-BK SSA-1372-BK (Domestic)--State/Local/Tribal Government	Form
SSA-1372-BK Advanced Notice of Termination of Child's Benefits SSA-1372-BK Revision_072011.pdf	Form
Current VersionSSA-1372-BK (Domestic) SLT Gov.pdf Current Version SSA-1372-BK	IC Document

IC Title:

SSA-1372-BK (Domestic)--State/Local/Tribal Government

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 404.350-404.352 20 CFR 404.367-404.368

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-1372-BK	Advanced Notice of Termination of Child's Benefits	SSA-1372-BK Revision_072011.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: 99,850

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	99,850	99,850
Annual IC Time Burden (Hours)	4,993	4,993
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current Version SSA-1372-BK	Current VersionSSA-1372-BK (Domestic) SLT Gov.pdf	11/29/2011

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