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

Documents and forms in this information collection
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	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

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-L8125-F6	www.ssa.gov	No		Fillable Printable
Other-Revised Privacy Act Statement			No		Printable Only
Other-Internet Screens			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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-L8125		10/06/2020
Current eIAR Screens		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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