Information Collection

Supplemental Security Income Claim Information Notice

IC 9219 under ICR 201708-0960-005 · OMB 0960-0324.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0324 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L8050-U3 Supplemental Security Income Claim Information Notice	Form and Instruction
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-L8050-U3 Supplemental Securrity Income Claim Information Notice SSA-L8050-U3 - Revised.pdf	Form and Instruction
SSA-L8050-U3 - Current.pdf SSA-L8050-U3 - Current	IC Document

IC Title:

Supplemental Security Income Claim Information Notice

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 Subpart B, 416.210 (To search for a specific CFR, visit the Code of Federal Regulations.)

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-L8050-U3	Supplemental Securrity Income Claim Information Notice	SSA-L8050-U3 - Revised.pdf		Yes	Yes	Fillable Fileable
Other-Revised PA Statement			Revised PA Statement.pdf		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 17,044

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	17,044	17,044
Annual IC Time Burden (Hours)	2,841	2,841
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-L8050-U3 - Current	SSA-L8050-U3 - Current.pdf	11/06/2017

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