Information Collection

SSA-5665-BK (Electronic)

IC 197497 under ICR 201703-0960-017 · OMB 0960-0646.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0646 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5665-BK (Elect SSA-5665-BK (Electronic)	Form and Instruction
ODAR Cover Letter (SSA-5665 Teacher Questionnaire) (2)(Final) (2).docx	Other-Cover Letter
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-5665-BK (Elect Teacher Questionnaire SSA-5665-BK - Revised.pdf	Form and Instruction
SSA-5665-BK - Current.pdf SSA-5665-BK - Current	IC Document

IC Title:

SSA-5665-BK (Electronic)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.1103(f)

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-5665-BK (Electronic)	Teacher Questionnaire	SSA-5665-BK - Revised.pdf	Yes	Yes	Fillable Fileable Signable
Other-Cover Letter			ODAR Cover Letter (SSA-5665 Teacher Questionnaire) (2)(Final) (2).docx	Yes	No	Paper Only
Other-Revised PA Statement			Revised PA Statement.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 293,375

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	293,375	-74,723	368,098
Annual IC Time Burden (Hours)	195,583	-49,816	245,399
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-5665-BK - Current	SSA-5665-BK - Current.pdf	05/17/2017

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