Information Collection

State, Local and Tribal Government

IC 45416 under ICR 201804-0960-006 · OMB 0960-0040.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0040 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Revised PA Statement.pdf	Other-Revised PA Statement
SSA-7160-F4 Employment Relationship Questionnaire SSA-7160 - Revised.pdf	Form
SSA-7160 - Current.pdf SSA-7160 - Current	IC Document

IC Title:

State, Local and Tribal Government

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 404.1007

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
Other-Revised PA Statement			Revised PA Statement.pdf		Yes	No	Fillable Printable
Form	SSA-7160-F4	Employment Relationship Questionnaire	SSA-7160 - Revised.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 800

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	800	800
Annual IC Time Burden (Hours)	333	333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-7160 - Current	SSA-7160 - Current.pdf	07/24/2018

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