Information Collection

SSA-5665-BK (paper)

IC 9683 under ICR 201404-0960-008 · OMB 0960-0646.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0646 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5665-BK SSA-5665-BK (paper)	Form and Instruction
ODAR Cover Letter (SSA-5665 Teacher Questionnaire) (2)(Final) (2).docx	Other-ODAR Cover Letter
SSA-5665-BK Teacher Questionnaire SSA-5665-BK Revised Version.pdf	Form and Instruction
ssa-5665 Current Version.pdf SSA-5665-BK (Current)	IC Document

IC Title:

SSA-5665-BK (paper)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.924(a)

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-5665-BK	Teacher Questionnaire	SSA-5665-BK Revised Version.pdf		No		Paper Only
Other-ODAR Cover Letter			ODAR Cover Letter (SSA-5665 Teacher Questionnaire) (2)(Final) (2).docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,562

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	2,562	-8,857	11,419
Annual IC Time Burden (Hours)	1,708	-5,905	7,613
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-5665-BK (Current)	ssa-5665 Current Version.pdf	06/11/2014

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