Information Collection

Important Information About Your Appeal, Waiver Rights, and Repayment Options (Paper Form)

IC 191893 under ICR 201507-0960-010 · OMB 0960-0779.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0779 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3105 Important Information About Your Appeal, Waiver Rights, and Repayment Options (Paper Form)	Form and Instruction
SSA-3105 Important Information About Your Appeal, Waiver Rights, ssa-3105(revised).pdf	Form and Instruction
ssa-3105(current).pdf SSA-3105 Current Version	IC Document

IC Title:

Important Information About Your Appeal, Waiver Rights, and Repayment Options (Paper Form)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.502 - 404.521

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-3105	Important Information About Your Appeal, Waiver Rights, and Repayment Options	ssa-3105(revised).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: 600,000

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	600,000	600,000
Annual IC Time Burden (Hours)	150,000	150,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3105 Current Version	ssa-3105(current).pdf	10/15/2015

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