Information Collection

Certification of Low Birth Weight for SSI Eligibility

IC 9777 under ICR 201709-0960-001 · OMB 0960-0720.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0720 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3830 Certification of Low Birth Weight for SSI Eligibility	Form
SSA-3830 Certification of Low Birth Weight for SSI Eligibility SSA-3830 (revised).pdf	Form
SSA-3830 (current).pdf SSA-3830 Current Version	IC Document

IC Title:

Certification of Low Birth Weight for SSI Eligibility

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 416.926a(m) (7) and (8) 20 CFR 416.924 20 CFR 416.931

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	SSA-3830	Certification of Low Birth Weight for SSI Eligibility	SSA-3830 (revised).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 28,125

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	28,125	28,125
Annual IC Time Burden (Hours)	7,031	7,031
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3830 Current Version	SSA-3830 (current).pdf	12/19/2017

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