Information Collection

Medicare-only Paper Form SSA-1

IC 191245 under ICR 201609-0960-001 · OMB 0960-0618.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0618 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1 Medicare-only Paper Form SSA-1	Form and Instruction
SSA-1-INST - Revised Version.pdf	Instruction
SSA-1 Application for Retirement Insurance Benefits SSA-1-BK - Revised Version.pdf	Form and Instruction
SSA-1-BK - Current Version.pdf Current SSA-1-BK	IC Document
SSA-1-INST - Current Version.pdf Current SSA-1-INST	IC Document

IC Title:

Medicare-only Paper Form SSA-1

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 404.310-.311 20 CFR 404.1501-.1512 20 CFR 404.315-.322 20 CFR 404.330-.333 20 CFR 404.601-.603

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-1	Application for Retirement Insurance Benefits	SSA-1-BK - Revised Version.pdf		No		Paper Only
Instruction			SSA-1-INST - Revised Version.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: 9,549

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	9,549	9,249	300
Annual IC Time Burden (Hours)	1,114	1,079	35
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-1-BK	SSA-1-BK - Current Version.pdf	08/06/2013
Current SSA-1-INST	SSA-1-INST - Current Version.pdf	08/06/2013

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