Information Collection

Application and Statement - SSA-3192

IC 9641 under ICR 202007-0960-006 · OMB 0960-0624.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0624 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3192 Application and Statement Application and Statement - SSA-3192	Form and Instruction
Revised PRA Statement - SSA-3192.pdf	Other-Revised PRA Statement
Revised PRA Statement - SSA-3192.pdf	Other-Revised PRA Statement
SSA-3192 Application and Statement SSA-3192 - Revised.pdf	Form and Instruction
SSA-3192 Application and Statement SSA-3192 - Revised (Signable).pdf	Form and Instruction
SSA-3192 - Current.pdf SSA-3192 - Current	IC Document
SSA-3192 - Current.pdf SSA-3192 - Current	IC Document

IC Title:

Application and Statement - SSA-3192

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 41 CFR 102-71.20 41 CFR 102-74.305 (To search for a specific CFR, visit the Code of Federal Regulations.)

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
Form and Instruction	SSA-3192				Yes	Yes	Fillable Fileable
Other-Revised PRA Statement					Yes	No	Fillable Fileable

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 390

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	Previously Approved
Annual Number of Responses for this IC	390	390
Annual IC Time Burden (Hours)	195	195
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3192 - Current		11/04/2020

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

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