Information Collection

Medicare-only Paper Form SSA-1

IC 191245 under ICR 201204-0960-011 · OMB 0960-0618.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0618 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1 Medicare-only Paper Form SSA-1	Form and Instruction
SSA-1-INST - Revised Version.pdf	Instruction
SSA-1 Application for Retirement Insurance Benefits SSA-1 - Revised Version.pdf	Form and Instruction
SSA-1-BK - Current Version.pdf Current SSA-1-BK	IC Document
SSA-1-INST - Current Version.pdf Current SSA-1-INST	IC Document

IC Title:

Medicare-only Paper Form SSA-1

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.315-.322 20 CFR 404.330-.333 20 CFR 404.601-.603 20 CFR 404.310-.311 20 CFR 404.1501-.1512

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 and Instruction	SSA-1	Application for Retirement Insurance Benefits	SSA-1 - Revised Version.pdf		No		Paper Only
Instruction			SSA-1-INST - 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: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	117	117
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-1-BK	SSA-1-BK - Current Version.pdf	08/17/2010
Current SSA-1-INST	SSA-1-INST - Current Version.pdf	08/17/2010

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