Information Collection

Certification of Low Birth Weight for SSI Eligibility

IC 9777 under ICR 201409-0960-004 · OMB 0960-0720.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0720 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3830 Certification of Low Birth Weight for SSI Eligibility	Form
SSA-3830 Certification of Low Birth Weight for SSI Eligibility ssa3830(revised).pdf	Form
ssa3830(current).pdf SSA-3830 Current Version	IC Document

IC Title:

Certification of Low Birth Weight for SSI Eligibility

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 416.931 20 CFR 416.926a(m) (7) and (8) 20 CFR 416.924

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	SSA-3830	Certification of Low Birth Weight for SSI Eligibility	ssa3830(revised).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: 28,125

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	28,125	625	27,500
Annual IC Time Burden (Hours)	7,031	156	6,875
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3830 Current Version	ssa3830(current).pdf	09/25/2014

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