Information Collection

Statement of Self-Employment Income

IC 43691 under ICR 201502-0960-010 · OMB 0960-0046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0046 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-766 Statement of Self-Employment Income	Form
PRA 0046.doc	Other-Paperwork Reduction Act
Privacy Act Statement Revised.doc	Other-Privacy Act Statement (revised
SSA-766 Statement of Self-Employment Income SSA-766 (revised).pdf	Form
ssa766(current).pdf SSA-766 Current Version	IC Document

IC Title:

Statement of Self-Employment Income

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 404.1096 20 CFR 404.610 20 CFR 404.110 20 CFR 404.611 20 CFR 404.101 20 CFR 422.405

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-766	Statement of Self-Employment Income	SSA-766 (revised).pdf	No	Paper Only
Other-Paperwork Reduction Act			PRA 0046.doc	No	Paper Only
Other-Privacy Act Statement (revised)			Privacy Act Statement Revised.doc	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,500

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	2,500	2,500
Annual IC Time Burden (Hours)	208	208
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-766 Current Version	ssa766(current).pdf	05/05/2015

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