Information Collection

SSA-5666 (Electronic)

IC 211838 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⚠️ Notice: This information collection may be referencing outdated material.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-5666 SSA-5666 (Electronic)	Form and Instruction
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-5666 Request for Administrative Information SSA-5666 - Revised.pdf	Form and Instruction
SSA-5666 - Current.pdf SSA-5666 - Current	IC Document

IC Title:

SSA-5666 (Electronic)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.924(a)

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-5666	Request for Administrative Information	SSA-5666 - Revised.pdf		Yes	Yes	Fillable Fileable Signable
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: 111,189

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	111,189	-26,401	137,590
Annual IC Time Burden (Hours)	55,595	-13,200	68,795
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-5666 - Current	SSA-5666 - Current.pdf	05/17/2017

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