Ssa-1709

Request for Workers' Compensation/Public Disability Benefit Information

OMB: 0960-0098

IC ID: 43695

Information Collection (IC) Details

View Information Collection (IC)

SSA-1709
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 404.408(e)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form SSA-1709 Request for Worker's Compensation/Public Disability Benefit Information SSA-1709 - Revised Form.pdf No   Printable Only

Income Security General Retirement and Disability

 

120,000 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 120,000 0 0 0 0 120,000
Annual IC Time Burden (Hours) 30,000 0 0 0 0 30,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Current SSA-1709 SSA-1709 - Current Form.pdf 05/17/2012
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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