Information Collection

Questionnaire for Children Claiming SSI Benefits

IC 9392 under ICR 201701-0960-013 · OMB 0960-0499.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0499 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3881 BK Questionnaire for Children Claiming SSI Benefits	Form
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-3881 BK Questionnaire for Children Claiming SSI Benefits SSA-3881-BK - Revised.pdf	Form
SSA-3881-BK - Current.pdf Questionnaire for Children Claiming SSI Benefits - Current	IC Document

IC Title:

Questionnaire for Children Claiming SSI Benefits

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 416.912(a)

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-3881 BK	Questionnaire for Children Claiming SSI Benefits	SSA-3881-BK - Revised.pdf		Yes	No	Fillable Printable
Other-Revised PA Statement			Revised 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: 130,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	130,000	20,000	110,000
Annual IC Time Burden (Hours)	65,000	10,000	55,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Questionnaire for Children Claiming SSI Benefits - Current	SSA-3881-BK - Current.pdf	03/22/2017

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