Information Collection

Ssa-l9781

IC 195823 under ICR 201703-0960-006 · OMB 0960-0369.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0369 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L9781 SSA-L9781	Form and Instruction
SSA-L9781 Retirement, Survivors and Disability Insurance: Earnings SSA 9781 (revised).pdf	Form and Instruction
2017 SSA 9781.pdf SSA-9781	IC Document

IC Title:

SSA-L9781

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 404.452-404.455

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 and Instruction	SSA-L9781	Retirement, Survivors and Disability Insurance: Earnings Estimate Form	SSA 9781 (revised).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: 472,437

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	Previously Approved
Annual Number of Responses for this IC	472,437	472,437
Annual IC Time Burden (Hours)	78,740	78,740
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-9781	2017 SSA 9781.pdf	05/31/2017

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