Information Collection

Agency/Employer Government Pension Offset Questionnaire

IC 9355 under ICR 201904-0960-007 · OMB 0960-0470.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0470 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-L4163 Agency/Employer Government Pension Offset Questionnaire Form
SSA-L4163 - Revised Privacy Act Statement.pdf Other-Privacy Act Statement
SSA-L4163 Agency/Employer Government Pension Offset Questionnaire SSA-L4163 (revised).pdf Form
SSA-L4163 (current).pdf SSA-L4163 - Current IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Agency/Employer Government Pension Offset Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.408(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-L4163	Agency/Employer Government Pension Offset Questionnaire	SSA-L4163 (revised).pdf		No		Paper Only
Other-Privacy Act Statement			SSA-L4163 - Revised Privacy Act Statement.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,911	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	2,911	1,911	1,000
Annual IC Time Burden (Hours)	146	96	50
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-L4163 - Current	SSA-L4163 (current).pdf	08/01/2019

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