Information Collection

Certificate of Support

IC 8859 under ICR 201807-0960-015 · OMB 0960-0001.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0001 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-760-F4 Certificate of Support	Form and Instruction
Privacy Act Statement revised.docx	Other-Privacy Act Statement 0001
SSA-760-F4 Certificate of Support SSA-7960 (revised).pdf	Form and Instruction
SSA-760-F4 (current).pdf SSA-760-F4 (current form)	IC Document

IC Title:

Certificate of Support

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 404.370 20 CFR 404.750 20 CFR 404.408a

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-760-F4	Certificate of Support	SSA-7960 (revised).pdf		No		Paper Only
Other-Privacy Act Statement 0001			Privacy Act Statement revised.docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 18,000

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	18,000	18,000
Annual IC Time Burden (Hours)	4,500	4,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-760-F4 (current form)	SSA-760-F4 (current).pdf	10/23/2018

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