Information Collection

Ssa-2855

IC 200252 under ICR 201410-0960-001 · OMB 0960-0481.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0481 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-2855 Statement of Funds You Recieve SSA-2855	Form and Instruction
SSA-2855 Statement of Funds You Recieve SSA-2855(Revised).pdf	Form and Instruction
ssa2855(current).pdf Current SSA-2855	IC Document

IC Title:

SSA-2855

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 416.1103(f)

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-2855				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20,000

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	Previously Approved
Annual Number of Responses for this IC	20,000	20,000
Annual IC Time Burden (Hours)	3,333	3,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-2855		10/14/2014

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

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