Information Collection

Identifying Information for Possible Direct Payment of Authorized Fees

IC 43718 under ICR 201902-0960-012 · OMB 0960-0730.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1695 Identifying Information for Possible Direct Payment of Authorized Fees	Form
SSA-1695 Identifying Information for Possible Direct Payment of A SSA-1695 - Revised.pdf	Form
SSA-1695 - Current.pdf SSA-1695 Current Version	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-1695	Identifying Information for Possible Direct Payment of Authorized Fees	SSA-1695 - Revised.pdf		No		Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

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	400,000	400,000
Annual IC Time Burden (Hours)	66,667	66,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-1695 Current Version	SSA-1695 - Current.pdf	02/15/2019

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