Information Collection

Supplemental Security Income Claim Information Notice

IC 9219 under ICR 201409-0960-012 · OMB 0960-0324.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0324 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L8050-U3 Supplemental Security Income Claim Information Notice	Form and Instruction
SSA-L8050-U3 Supplemental Securrity Income Claim Information Notice SSA-L8050.pdf	Form and Instruction

IC Title:

Supplemental Security Income Claim Information Notice

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 Subpart B, 416.210 (To search for a specific CFR, visit the Code of Federal Regulations.)

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-L8050-U3	Supplemental Securrity Income Claim Information Notice	SSA-L8050.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: 17,044

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	17,044	9,544	7,500
Annual IC Time Burden (Hours)	2,841	1,591	1,250
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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