Information Collection

Disability Report - Adult, (Internet Version)

IC 179420 under ICR 201501-0960-004 · OMB 0960-0579.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0579 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
i3368 Screenshots -- Revised.pdf secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Other-SSA-3368 (Internet)
i3368 Privacy Act Statement.doc	Other-Privacy Act Statement
i3368 Screenshots - Revised to Include CAL.pdf secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Other-Internet Screens
i3368 Marriage (1st Party) 0 5 12172012 (2).docx	Other-i3368 Marriage (1st Party)
i3368 Marriage (3rd Party) 0 2 12172012 (2).docx	Other-i3368 Marriage (3rd Party
i3368 - Revised i3368 Marriage Screenshots.doc	Other-Internet Screens
Internet Screens -- Current.pdf i3368 -- Current Screens	IC Document

IC Title:

Disability Report - Adult, (Internet Version)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1512 20 CFR 416.912

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-SSA-3368 (Internet)	i3368 Screenshots -- Revised.pdf	https://secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Yes	Yes	Fillable Fileable
Other-Privacy Act Statement	i3368 Privacy Act Statement.doc		Yes	Yes	Printable Only
Other-Internet Screens	i3368 Screenshots - Revised to Include CAL.pdf	https://secure.ssa.gov/apps6z/i3369/ee001-fe.jsp	Yes	Yes	Fillable Fileable Signable
Other-i3368 Marriage (1st Party)	i3368 Marriage (1st Party) 0 5 12172012 (2).docx	www.socialsecurity.gov	Yes	Yes	Fillable Fileable Signable
Other-i3368 Marriage (3rd Party	i3368 Marriage (3rd Party) 0 2 12172012 (2).docx	www.socialsecurity.gov	Yes	Yes	Fillable Fileable Signable
Other-Internet Screens	i3368 - Revised i3368 Marriage Screenshots.doc	www.socialsecurity.gov	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: 421,226

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	421,226	421,226
Annual IC Time Burden (Hours)	631,839	631,839
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
i3368 -- Current Screens	Internet Screens -- Current.pdf	06/12/2009

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