Information Collection

Government Pension Questionnaire

IC 9142 under ICR 201701-0960-011 · OMB 0960-0160.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0160 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3885 Government Pension Questionnaire	Form and Instruction
SSA-3885 - MCS Screens.docx	Other-Internal Screens
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-3885 Government Pension Questionnaire SSA-3885 - Revised.pdf	Form and Instruction
SSA-3885 - Current.pdf SSA-3885 - Current	IC Document

IC Title:

Government Pension Questionnaire

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 404.408a

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3885	Government Pension Questionnaire	SSA-3885 - Revised.pdf	No		Printable Only
Other-Internal Screens			SSA-3885 - MCS Screens.docx	Yes	Yes	Fillable Fileable Signable
Other-Revised PA Statement			Revised PA Statement.pdf	No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 76,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 60 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	76,000	76,000
Annual IC Time Burden (Hours)	16,467	16,467
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3885 - Current	SSA-3885 - Current.pdf	03/13/2017

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