Information Collection

f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398

IC 184462 under ICR 201506-0960-011 · OMB 0960-0644.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0644 can be found here:

2024-04-08 - No material or nonsubstantive change to a currently approved collection
2024-01-18 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1391 Employment Network Payment Request Form f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction
Form SSA-1389 EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request) f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction
Form SSA-1393 Employment Network Supplemental Earnings Statement f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction
Form SSA-1399 Auto Pay Request Form f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction
Form SSA-1396 Earnings Inquiry Request Form f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction
Form SSA-1398 Self-Employment Income (SEI) Form Beneficiary Quarterly Report Self-Employment f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398	Form and Instruction
DemoDeck.pptx	Other-screens
SSA-1391 Employment Network Payment Request Form SSA-1391 - Revised Version.pdf	Form and Instruction
SSA-1389 EN Services Certification Statement (For Use with Phase SSA-1389 - Revised Version.pdf	Form and Instruction
SSA-1393 Employment Network Supplemental Earnings Statement SSA-1393 - Revised Version.pdf	Form and Instruction
SSA-1399 Auto Pay Request Form SSA-1399 - Revised Version.pdf	Form and Instruction
SSA-1396 Earnings Inquiry Request Form SSA-1396 - Revised Version.pdf	Form and Instruction
SSA-1398 Self-Employment Income (SEI) Form Beneficiary Quarterly SSA-1398 - Revised Version.pdf	Form and Instruction
SSA-1389 - Current Version.pdf Current SSA-1389	IC Document
SSA-1391 - Current Version.pdf Current SSA-1391	IC Document
SSA-1393 - Current Version.pdf Current SSA-1393	IC Document
SSA-1396 - Current Version.pdf Current SSA-1396	IC Document
SSA-1398 - Current Version.pdf Current SSA-1398	IC Document
SSA-1399 - Current Version.pdf Current SSA-1399	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1393; SSA-1399; SSA-1396; SSA-1398

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 411.575

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-1391	Employment Network Payment Request Form	SSA-1391 - Revised Version.pdf	No		Paper Only
Form and Instruction	SSA-1389	EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request)	SSA-1389 - Revised Version.pdf	No		Paper Only
Form and Instruction	SSA-1393	Employment Network Supplemental Earnings Statement	SSA-1393 - Revised Version.pdf	No		Printable Only
Form and Instruction	SSA-1399	Auto Pay Request Form	SSA-1399 - Revised Version.pdf	Yes	No	Printable Only
Form and Instruction	SSA-1396	Earnings Inquiry Request Form	SSA-1396 - Revised Version.pdf	Yes	No	Printable Only
Form and Instruction	SSA-1398	Self-Employment Income (SEI) Form Beneficiary Quarterly Report Self-Employment	SSA-1398 - Revised Version.pdf	Yes	No	Printable Only
Other-screens			DemoDeck.pptx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,805

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,805	2,805
Annual IC Time Burden (Hours)	1,870	1,870
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-1389	SSA-1389 - Current Version.pdf	04/05/2012
Current SSA-1391	SSA-1391 - Current Version.pdf	04/05/2012
Current SSA-1393	SSA-1393 - Current Version.pdf	04/05/2012
Current SSA-1396	SSA-1396 - Current Version.pdf	04/05/2012
Current SSA-1398	SSA-1398 - Current Version.pdf	04/05/2012
Current SSA-1399	SSA-1399 - Current Version.pdf	04/05/2012

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