Information Collection

Statement of Income and Resources

IC 9097 under ICR 201702-0960-003 · OMB 0960-0124.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0124 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8010 Statement of Income and Resources	Form
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-8010 Statement of Income and Resources (MSSICS Screens) SSA-8010-MSSICS Screens.docx	Form
SSA-8010-BK Statement of Income and Resources SSA-8010-BK - Revised.pdf	Form
SSA-8010-BK - Current.pdf SSA-8010-BK - Current	IC Document

IC Title:

Statement of Income and Resources

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.704 20 CFR 416.207 20 CFR 416.708 20 CFR 416.301-416.310

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	SSA-8010	Statement of Income and Resources (MSSICS Screens)	SSA-8010-MSSICS Screens.docx	Yes	Yes	Fillable Fileable Signable
Form	SSA-8010-BK	Statement of Income and Resources	SSA-8010-BK - Revised.pdf	No		Paper Only
Other-Revised PA Statement			Revised PA Statement.pdf	No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 341,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 82 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	341,000	341,000
Annual IC Time Burden (Hours)	147,767	147,767
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-8010-BK - Current	SSA-8010-BK - Current.pdf	03/27/2017

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