Information Collection

e) Paper Form SSA-L8125-F6

IC 186510 under ICR 201406-0960-004 · OMB 0960-0546.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0546 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L8125-F6 e) Paper Form SSA-L8125-F6	Form and Instruction
eIAR 2 4 Internet Screens(revised).pdf	Other-Internet screens (revised)
SSA-L8125-F6 Supplemental Security Income Notice of Interim Assistanc SSA-L8125-F6 (revised).pdf	Form and Instruction
SSA-L8125-F6 (current).pdf Supplemental Security Income Notice of Interim Assistance Reimbursement (current)	IC Document
eIAR 2 4 Internet Screens(current).pdf eIAR Internet Screens(current)	IC Document

IC Title:

e) Paper Form SSA-L8125-F6

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 416.1906, 416.1908, 416.1910 20 CFR 416.1901-416.1902, 416.1904 20 CFR 416.1920, 416.1922

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-L8125-F6	Supplemental Security Income Notice of Interim Assistance Reimbursement	SSA-L8125-F6 (revised).pdf		No		Paper Only
Other-Internet screens (revised)			eIAR 2 4 Internet Screens(revised).pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,524

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	Previously Approved
Annual Number of Responses for this IC	1,524	1,524
Annual IC Time Burden (Hours)	762	762
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supplemental Security Income Notice of Interim Assistance Reimbursement (current)	SSA-L8125-F6 (current).pdf	09/19/2014
eIAR Internet Screens(current)	eIAR 2 4 Internet Screens(current).pdf	09/19/2014

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