Statement of Claimant or Other Person

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0183 can be found here:

Documents and Forms

Document Name Document Type
Form G-93 (11-12) Statement of Claimant or Other Person Form
G-93 (11-12) Statement of Claimant or Other Person Form G-93 (11-12).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Claimant or Other Person	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 217 20 CFR 320

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	G-93 (11-12)	Statement of Claimant or Other Person	Form G-93 (11-12).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System	FR Citation: 79 FR 58874

Number of Respondents: 175	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	175	-700	875
Annual IC Time Burden (Hours)	44	-175	219
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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