SSA-1372-BK (Domestic)- Representative Payees

Advanced Notice of Termination of Child's Benefits, and Student's Statement Regarding School Attendance

Documents and Forms

Document Name Document Type
Form SSA-1372-BK SSA-1372-BK (Domestic)- Representative Payees Form
0105 Privacy Act Statement (revised).docx Other-Revised Privacy Act Statement
PRA 0105.docx Other-Revised Paperwork Reduction Ac
SSA-1372-BK Advanced Notice of Termination of Child's Benefits SSA-1372-BK (revised).pdf Form
SSA-1372-BK (current).pdf Advanced Notice of Termination of Child's Benefits IC Document

Information Collection (IC) Details

IC Title:	SSA-1372-BK (Domestic)- Representative Payees	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-1372-BK	Advanced Notice of Termination of Child's Benefits	SSA-1372-BK (revised).pdf	No	Paper Only
Other-Revised Privacy Act Statement			0105 Privacy Act Statement (revised).docx	No	Paper Only
Other-Revised Paperwork Reduction Act Statement			PRA 0105.docx	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 23,318	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	23,318	23,318
Annual IC Time Burden (Hours)	1,166	1,166
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Advanced Notice of Termination of Child's Benefits	SSA-1372-BK (current).pdf	08/25/2020

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