Information Collection

State/Local/Tribal Government: Paper SSA-11-BK

IC 186313 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form SSA-11-BK State/Local/Tribal Government: Paper SSA-11-BK Form
SSA-11-BK revised privacy act statement.doc Other-Revised Privacy Act Statement
SSA-11-BK Request to be Selected as a Payee SSA-11-BK (revised).pdf Form
SSA-11-BK (current).pdf Current SSA-11-BK IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State/Local/Tribal Government: 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 404.2010-404.2055 20 CFR 416.601-416.665

Information Collection 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 a Payee	SSA-11-BK (revised).pdf		No		Paper Only
Other-Revised Privacy Act Statement 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: 340	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	340	0	340
Annual IC Time Burden (Hours)	68	6	62
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.