Information Collection

c) 20 CFR 411.200(b) - SSA-1375; SSA-L1373; SSA-L1374

IC 184457 under ICR 201204-0960-004 · OMB 0960-0644.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0644 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-1375 c) 20 CFR 411.200(b) - SSA-1375; SSA-L1373; SSA-L1374 Form
SSA-L1373 - Revised Version.pdf Instruction
SSA-L1374 - Revised Version.pdf Instruction
SSA-1375 Ticket to Work Progress Review Form SSA-1375 - Revised Version.pdf Form
SSA-L1373 - Current Version.pdf Current SSA-L1373 IC Document
SSA-1375 - Current Version.pdf Current SSA-1375 IC Document
SSA-L1374 - Current Version.pdf Current SSA-L1374 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	c) 20 CFR 411.200(b) - SSA-1375; SSA-L1373; SSA-L1374	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 411.200(b)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-1375	Ticket to Work Progress Review Form	SSA-1375 - Revised Version.pdf	No	Paper Only
Instruction			SSA-L1373 - Revised Version.pdf	No	Paper Only
Instruction			SSA-L1374 - 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: 112,362	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	112,362	-14,638	127,000
Annual IC Time Burden (Hours)	28,091	-3,659	31,750
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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