Information Collection

Modified Benefit Formula Questionnaire-Employer

IC 9371 under ICR 201701-0960-016 · OMB 0960-0477.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0477 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-58 Modified Benefit Formula Questionnaire-Employer Form
Privacy Act Statement 0477.doc Other-Privacy Act Statement (revised
PRA 0477.doc Other-Paperwork Reduction Act Statem
SSA-58 Modified Benefit Formula Questionnaire-Employer SSA-58(revised).pdf Form
ssa-58(current).pdf SSA-58 (current) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Modified Benefit Formula Questionnaire-Employer	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1512-404.1515 20 CFR 416.912-416.915

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-58	Modified Benefit Formula Questionnaire-Employer	SSA-58(revised).pdf	No	Paper Only
Other-Privacy Act Statement (revised)			Privacy Act Statement 0477.doc	No	Paper Only
Other-Paperwork Reduction Act Statement Revised			PRA 0477.doc	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	10,000	10,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-58 (current)	ssa-58(current).pdf	03/01/2017

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