Information Collection

Statement of Care and Responsibility for Beneficiary

IC 43697 under ICR 201803-0960-008 · OMB 0960-0109.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0109 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-788 Statement of Care and Responsibility for Beneficiary	Form
SSA-788 Statement of Care and Responsibility for Beneficiary SSA-788 - Revised.pdf	Form
SSA-788 - Current.pdf SSA-788 - Current	IC Document

IC Title:

Statement of Care and Responsibility for Beneficiary

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 404.2025 20 CFR 408.620 20 CFR 408.625 20 CFR 404.2020 20 CFR 416.625 20 CFR 416.620

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-788	Statement of Care and Responsibility for Beneficiary	SSA-788 - Revised.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: 130,000

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	130,000	130,000
Annual IC Time Burden (Hours)	21,667	21,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-788 - Current	SSA-788 - Current.pdf	05/30/2018

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