Information Collection

Ssa-85

IC 183775 under ICR 201703-0960-010 · OMB 0960-0189.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0189 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-85 SSA-85	Form
SSA-85 - Revised PA Statement.pdf	Other-Revised PA Statement
SSA-85 Information Needed to Review Your Social Security Claim SSA-85 - Revised Version.pdf	Form
SSA-85 - Current Version.pdf Current SSA-85	IC Document

IC Title:

SSA-85

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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-85	Information Needed to Review Your Social Security Claim	SSA-85 - Revised Version.pdf		No		Paper Only
Other-Revised PA Statement			SSA-85 - 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: 3,850

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	3,850	3,850
Annual IC Time Burden (Hours)	321	321
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-85	SSA-85 - Current Version.pdf	08/18/2017

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