Information Collection

20 CFR 404.1503b(c) & 416.903b(c)

IC 222015 under ICR 201609-0960-014 · OMB 0960-0803.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0803 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
BBA 812 - Paper Fact Sheet.pdf	Instruction
BBA812 - Internet Fact Sheet Screen Shots.pdf www.ssa.gov	Instruction
BBA 812 - Model Repsonse - For Sections 208 or 1632 of the Act.pdf www;ssa.gov	Other-Sample Template
BBA 812 - Model Response - For Section 1128 of the Act.pdf www.ssa.gov	Other-Sample Template
BBA 812 - Model Response - For Section 1129 of the Act.pdf www.ssa.gov	Other-Sample Template

IC Title:

20 CFR 404.1503b(c) & 416.903b(c)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 404.1503b(c) 20 CFR 416.903b(c)

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	BBA 812 - Paper Fact Sheet.pdf		No		Paper Only
Instruction	BBA812 - Internet Fact Sheet Screen Shots.pdf	www.ssa.gov	Yes	No	Printable Only
Other-Sample Template	BBA 812 - Model Repsonse - For Sections 208 or 1632 of the Act.pdf	www;ssa.gov	Yes	No	Printable Only
Other-Sample Template	BBA 812 - Model Response - For Section 1128 of the Act.pdf	www.ssa.gov	Yes	No	Printable Only
Other-Sample Template	BBA 812 - Model Response - For Section 1129 of the Act.pdf	www.ssa.gov	Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.