Information Collection

SSA-827 with wet signature(paper version)

IC 9639 under ICR 201703-0960-023 · OMB 0960-0623.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0623 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-827 SSA-827 with wet signature(paper version)	Form and Instruction
Revised Privacy Act Statement - SSA-827.pdf	Other-Revised Privacy Act Statement
SSA-827 Authorization To Disclose Information To The Social Secu SSA-827 - Revised Version.pdf www.ssa.gov/online/ssa-827.pdf	Form and Instruction
SSA-827 - Current Version.pdf Current SSA-827	IC Document

IC Title:

SSA-827 with wet signature(paper version)

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 416.912 20 CFR 404.1512 45 CFR 160 & 164

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-827	Authorization To Disclose Information To The Social Security Administration	SSA-827 - Revised Version.pdf	http://www.ssa.gov/online/ssa-827.pdf	Yes	No	Fillable Printable
Other-Revised Privacy Act Statement			Revised Privacy Act Statement - SSA-827.pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,055,807

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,055,807	-385,245	1,441,052
Annual IC Time Burden (Hours)	175,968	-64,207	240,175
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-827	SSA-827 - Current Version.pdf	07/31/2017

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