Information Collection

Application and Statement

IC 9641 under ICR 201205-0960-009 · OMB 0960-0624.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0624 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3192 Application and Statement Application and Statement	Form and Instruction
SSA-3192 Application and Statement SSA-820 Revised Version.pdf	Form and Instruction
SSA-820 Current Version.pdf SSA-3192 Current Version	IC Document

IC Title:

Application and Statement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 41 CFR 101.20-104.2

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-3192	Application and Statement	SSA-820 Revised Version.pdf		No		Paper Only

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 75

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	75	75
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3192 Current Version	SSA-820 Current Version.pdf	05/11/2012

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