Information Collection

e) State Computation of Reimbursement Due from SSA Using Paper Form SSA-L8125 or eIAR

IC 186510 under ICR 202007-0960-004 · OMB 0960-0546.

Documents and Forms

Document Name Document Type
Form SSA-L8125-F6 Supplemental Security Income Notice of Interim Assistance Reimbursement e) State Computation of Reimbursement Due from SSA Using Paper Form SSA-L8125 or eIAR Form and Instruction
Revised PA Statement - SSA-L8125.pdf Other-Revised Privacy Act Statement
Revised PA Statement - SSA-L8125.pdf Other-Revised Privacy Act Statement
eIAR - Internet Screens (Revised).pdf Other-Internet Screens
eIAR - Internet Screens (Revised).pdf Other-Internet Screens
SSA-L8125-F6 Supplemental Security Income Notice of Interim Assistanc SSA-L8125 - Revised Version.pdf Form and Instruction
SSA-L8125-F6 Supplemental Security Income Notice of Interim Assistanc SSA-L8125 (Revised Version - Signature Removal).pdf www.ssa.gov Form and Instruction
SSA-L8125 - Current Version.pdf Current SSA-L8125 IC Document
SSA-L8125 - Current Version.pdf Current SSA-L8125 IC Document
eIAR - Internet Screens (Current).pdf Current eIAR Screens IC Document
eIAR - Internet Screens (Current).pdf Current eIAR Screens IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	e) State Computation of Reimbursement Due from SSA Using Paper Form SSA-L8125 or eIAR	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1906, 416.1908, 416.1910 20 CFR 416.1901-416.1902, 416.1904 20 CFR 416.1920, 416.1922

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-L8125-F6	Supplemental Security Income Notice of Interim Assistance Reimbursement	SSA-L8125 (Revised Version - Signature Removal).pdf	www.ssa.gov	No		Fillable Printable
Other-Revised Privacy Act Statement			Revised PA Statement - SSA-L8125.pdf		No		Printable Only
Other-Internet Screens			eIAR - Internet Screens (Revised).pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 38	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	38	-1,486	1,524
Annual IC Time Burden (Hours)	19	-743	762
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-L8125	SSA-L8125 - Current Version.pdf	10/06/2020
Current eIAR Screens	eIAR - Internet Screens (Current).pdf	10/06/2020

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

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