Information Collection

Ssa-1003-f3

IC 182041 under ICR 201609-0960-002 · OMB 0960-0036.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0036 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-1003-F3 SSA-1003-F3 Form
Updated PA Statement.pdf Other-Revised PA Statement
SSA-1003-F3 Statement of Agricultural Employer for Years 1988 and La SSA-1003-F3 (Revised).pdf Form
SSA-1003-F3 (Current).pdf SSA-1003-F3 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SSA-1003-F3	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 404.702 20 CFR 404.1056 20 CFR 404.802

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-1003-F3	Statement of Agricultural Employer for Years 1988 and Later	SSA-1003-F3 (Revised).pdf		Yes	No	Fillable Printable
Other-Revised PA Statement			Updated PA Statement.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Farms, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	25,000	25,000
Annual IC Time Burden (Hours)	12,500	12,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-1003-F3	SSA-1003-F3 (Current).pdf	01/11/2017

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