Information Collection

Statement of Employer

IC 43689 under ICR 201206-0960-011 · OMB 0960-0030.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0030 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-7011-F4 Statement of Employer	Form and Instruction
SSA-7011-F4 Statement of Employer SSA-7011 - Revised Version.pdf	Form and Instruction
SSA- 7011 - Current Version.pdf Currently Approved SSA-7011	IC Document

IC Title:

Statement of Employer

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 404.801-404.803

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-7011-F4	Statement of Employer	SSA-7011 - 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: 462,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	462,000	-463,000	925,000
Annual IC Time Burden (Hours)	154,000	-154,333	308,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Currently Approved SSA-7011	SSA- 7011 - Current Version.pdf	07/06/2012

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