Medicare-only Paper Form SSA-1

Social Security Benefits Application

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0618 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-1 Medicare-only Paper Form SSA-1 Form and Instruction
SSA-1-BK Privacy Act Statement (revised).doc Other-Revised Privacy Act Statement
SSA-1 Application for Retirement Insurance Benefits SSA-1-BK - Revised Version.pdf Form and Instruction
Current SSA-1.pdf Current SSA-1-BK IC Document

Information Collection (IC) Details

IC Title:	Medicare-only Paper Form SSA-1	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 404.310-.311 20 CFR 404.1501-.1512 20 CFR 404.315-.322 20 CFR 404.330-.333 20 CFR 404.601-.603

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-1	Application for Retirement Insurance Benefits	SSA-1-BK - Revised Version.pdf		No		Paper Only
Other-Revised Privacy Act Statement			SSA-1-BK Privacy Act Statement (revised).doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 173	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	173	-9,376	9,549
Annual IC Time Burden (Hours)	20	-1,094	1,114
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-1-BK	Current SSA-1.pdf	08/02/2017

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