Information Collection

Private Sector: Paper SSA-11-BK

IC 186310 under ICR 201812-0960-004 · OMB 0960-0014.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0014 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-11-BK Private Sector: Paper SSA-11-BK	Form
SSA-11-BK revised privacy act statement.doc	Other-Privacy Act Statement (revised
SSA-11-BK Request to be Selected as Payee SSA-11-BK (revised).pdf	Form
SSA-11-BK (current).pdf Current SSA-11-BK	IC Document

IC Title:

Private Sector: Paper SSA-11-BK

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 416.601-416.665 20 CFR 404.2010-404.2055

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-11-BK	Request to be Selected as Payee	SSA-11-BK (revised).pdf		No		Paper Only
Other-Privacy Act Statement (revised) 0014			SSA-11-BK revised privacy act statement.doc		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,840

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	6,840	3,780	3,060
Annual IC Time Burden (Hours)	1,368	807	561
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-11-BK	SSA-11-BK (current).pdf	02/07/2019

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