Information Collection

Modified Benefit Formula Questionnaire

IC 9252 under ICR 201702-0960-001 · OMB 0960-0395.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0395 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-150 Modified Benefit Formula Questionnaire	Form and Instruction
SSA-150 MCS Screens.pdf	Other-Internal Screens
0395 Privacy Act Statement (revised).doc	Other-Revised Privacy Act Statement
0395 PRA (revised).doc	Other-Paperwork Reduction Act Statem
SSA-150 Modified Benefit Formula Questionnaire ssa-150 (revised).pdf	Form and Instruction
ssa-150 (current).pdf SSA-150 (current)	IC Document

IC Title:

Modified Benefit Formula 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:

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-150	Modified Benefit Formula Questionnaire	ssa-150 (revised).pdf	No		Fillable Printable
Other-Internal Screens			SSA-150 MCS Screens.pdf	Yes	Yes	Fillable Fileable
Other-Revised Privacy Act Statement			0395 Privacy Act Statement (revised).doc	No		Printable Only
Other-Paperwork Reduction Act Statement Revised			0395 PRA (revised).doc	No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	90,000	90,000
Annual IC Time Burden (Hours)	12,000	12,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-150 (current)	ssa-150 (current).pdf	04/26/2017

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