Information Collection

State Mental Institution Policy Review

IC 9081 under ICR 201701-0960-001 · OMB 0960-0110.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0110 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-9584-BK State Mental Institution Policy Review Form
Updated PA Statement.pdf Other-Revised PA Statement
SSA-9584-BK State Mental Instintution Policy Review SSA-9584-BK - Updated.pdf Form
SSA-9584-BK - Current.pdf SSA-9584-BK (Current) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Mental Institution Policy Review	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 404.2035 20 CFR 404.2065 20 CFR 416.635 20 CFR 416.665

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-9584-BK	State Mental Instintution Policy Review	SSA-9584-BK - Updated.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: 69	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	69	-9	78
Annual IC Time Burden (Hours)	69	-9	78
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-9584-BK (Current)	SSA-9584-BK - Current.pdf	01/25/2017

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