Information Collection

Application and Statement - SSA-3192

IC 9641 under ICR 201405-0960-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form SSA-3192 Application and Statement - SSA-3192 Form and Instruction
SSA-3192 Application and Statement SSA-3192 - Revised Version.pdf Form and Instruction
SSA-3192 - Current Version.pdf Current SSA-3192 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application and Statement - SSA-3192	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 102-71.20 41 CFR 102-74.305 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection 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-3192 - 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: 290	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	290	215	75
Annual IC Time Burden (Hours)	145	107	38
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-3192	SSA-3192 - Current Version.pdf	07/28/2014

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