Information Collection

Modified Benefit Formula Questionnaire-Employer

IC 9371 under ICR 202004-0960-003 · OMB 0960-0477.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-58 Modified Benefit Formula Questionnaire-Employer Modified Benefit Formula Questionnaire-Employer	Form
Privacy Act Statement 0477.doc	Other-Privacy Act Statement (revised
Privacy Act Statement 0477.doc	Other-Privacy Act Statement (revised
PRA 0477.doc	Other-Paperwork Reduction Act Statem
PRA 0477.doc	Other-Paperwork Reduction Act Statem
SSA-58 Modified Benefit Formula Questionnaire-Employer SSA-58 (revised).pdf	Form
SSA-58 Modified Benefit Formula Questionnaire-Employer SSA-58 (revised).pdf	Form
SSA-58 (current).pdf SSA-58 (current)	IC Document
SSA-58 (current).pdf SSA-58 (current)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1512-404.1515 20 CFR 416.912-416.915

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Form	SSA-58	No	Fillable Printable
Other-Privacy Act Statement (revised)		No	Paper Only
Other-Paperwork Reduction Act Statement Revised		No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 26,925

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	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	26,925	0	-3,075	30,000
Annual IC Time Burden (Hours)	4,488	3,142	-8,654	10,000
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-58 (current)		08/03/2020

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

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