Information Collection

Ssa-1002-f3

IC 8936 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1002-F3 Statement of Agricultural Employer (Years Prior to 1988) SSA-1002-F3	Form
Updated PA Statement.pdf	Other-Revised PA Statement
SSA-1002-F3 Statement of Agricultural Employer (Years Prior to 1988) SSA-1002-F3 (Revised).pdf	Form
SSA-1002-F3 (Current).pdf SSA-1002- F3	IC Document

IC Title:

SSA-1002-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 404.802 20 CFR 404.1056 20 CFR 404.702

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-1002-F3				Yes	No	Fillable Printable
Other-Revised PA Statement					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: 7,500

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Farms

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	7,500	7,500
Annual IC Time Burden (Hours)	3,750	3,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-1002- F3		01/11/2017

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

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