Information Collection

Request for Social Security Statement - Internet Version

IC 180317 under ICR 201203-0960-002 · OMB 0960-0466.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0466 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Internet Screens for SSA-7004 - Revised.pdf www.ssa.gov/mystatement/	Other-Internet Screens & Instrructio
Internet Screens for SSA-7004 - Current.pdf Current Internet Screens for SSA-7004	IC Document

IC Title:

Request for Social Security Statement - Internet Version

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.810

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-Internet Screens & Instrruction			Internet Screens for SSA-7004 - Revised.pdf	http://www.ssa.gov/mystatement/	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 426,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	426,000	426,000
Annual IC Time Burden (Hours)	35,500	35,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current Internet Screens for SSA-7004	Internet Screens for SSA-7004 - Current.pdf	03/26/2010

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