Information Collection

a) 411.140(d)(3); 411.325(a); 411.150(b)(3) - SSA-1365

IC 184502 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⚠️ Notice: This information collection may be referencing outdated material.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-1365 a) 411.140(d)(3); 411.325(a); 411.150(b)(3) - SSA-1365 Form
SSA-1365 State Agency Ticket Assignment Form Ticket to Work and S SSA-1365 - Revised Version.pdf Form
SSA-1365 - Current Version.pdf Current Version of the SSA-1365 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	a) 411.140(d)(3); 411.325(a); 411.150(b)(3) - SSA-1365	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 411.140(d)(3) 20 CFR 411.150(b)(3) 20 CFR 411.325(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-1365	State Agency Ticket Assignment Form Ticket to Work and Self-Sufficiency Program	SSA-1365 - 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: 2,370	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,370	-9,960	12,330
Annual IC Time Burden (Hours)	593	-11,737	12,330
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current Version of the SSA-1365	SSA-1365 - Current Version.pdf	04/05/2012

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