Information Collection

Individuals/Households: Paper SSA-11-BK

IC 8897 under ICR 201602-0960-014 · OMB 0960-0014.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0014 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-11-BK Individuals/Households: Paper SSA-11-BK	Form
SSA-11-BK Request to be Selected as a Payee SSA-11-BK revised.pdf	Form
SSA-11-BK(current).pdf Current SSA-11-BK	IC Document

IC Title:

Individuals/Households: Paper SSA-11-BK

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 416.601-416.665 20 CFR 404.2010-404.2055

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	SSA-11-BK	Request to be Selected as a Payee	SSA-11-BK 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: 91,800

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	91,800	91,800
Annual IC Time Burden (Hours)	16,830	16,830
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-11-BK	SSA-11-BK(current).pdf	05/03/2016

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