Information Collection

Completing Form SSA-89

IC 181576 under ICR 201912-0960-002 · OMB 0960-0760.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0760 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SSA-89 - Revised PA and PRA Statements.pdf	Other-Revised PA & PRA Statements
SSA-89 Authroiztion for the Social Security Administration to R SSA-89 - Revised.pdf	Form
SSA-89 - Current.pdf SSA-89 - Current	IC Document

IC Title:

Completing Form SSA-89

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 401.100

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
Other-Revised PA & PRA Statements			SSA-89 - Revised PA and PRA Statements.pdf		Yes	No	Fillable Printable
Form	SSA-89	Authroiztion for the Social Security Administration to Release SSN Verification	SSA-89 - Revised.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,500,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,500,000	-300,000	2,800,000
Annual IC Time Burden (Hours)	125,000	-15,000	140,000
Annual IC Cost Burden (Dollars)	0	-3,920,000	3,920,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-89 - Current	SSA-89 - Current.pdf	03/10/2020

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