Information Collection

Important Information About Your Appeal, Waiver Rights, and Repayment Options (Paper Form)

IC 191893 under ICR 201210-0960-005 · OMB 0960-0779.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0779 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-3105 Important Information About Your Appeal, Waiver Rights, and Repayment Options (Paper Form) Form and Instruction
SSA-3105 Important Information About Your Appeal, Waiver Rights, SSA 3105 Final.pdf Form and Instruction
SSA-3105 Current Version.pdf SSA-3105 Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Important Information About Your Appeal, Waiver Rights, and Repayment Options (Paper Form)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.502 - 404.521

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3105	Important Information About Your Appeal, Waiver Rights, and Repayment Options	SSA 3105 Final.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: 600,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	600,000	600,000
Annual IC Time Burden (Hours)	150,000	150,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-3105 Current Version	SSA-3105 Current Version.pdf	11/16/2012

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