Information Collection

Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form

IC 191893 under ICR 201807-0960-017 · OMB 0960-0779.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0779 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3105 Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form	Form and Instruction
Revised Privacy Act Statement - 0779.pdf	Other-Revised Privacy Act Statement
SSA-3105 Important Information About Your Appeal, Waiver Rights, SSA-3105 - Revised Version.pdf	Form and Instruction
SSA-3105 - Current Version.pdf SSA-3105 Current Version	IC Document

IC Title:

Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.502 - 404.521

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-3105	Important Information About Your Appeal, Waiver Rights, and Repayment Options	SSA-3105 - Revised Version.pdf		No		Paper Only
Other-Revised Privacy Act Statement			Revised Privacy Act Statement - 0779.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500,000

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	500,000	-100,000	600,000
Annual IC Time Burden (Hours)	125,000	-25,000	150,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3105 Current Version	SSA-3105 - Current Version.pdf	11/14/2018

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