Information Collection

Statement Regarding Contributions

IC 8915 under ICR 202008-0960-012 · OMB 0960-0020.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0020 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-783 Statement Regarding Contributions	Form and Instruction
SSA-783 - Revised PA and PRA Statements.pdf	Other-Revised Privacy Act and PRA St
SSA-783 Statement Regarding Contributions SSA-783 - Revised Version.pdf	Form and Instruction
SSA-783 - Current Version.pdf Current SSA-783	IC Document

IC Title:

Statement Regarding Contributions

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 404.736 20 CFR 404.360-.404.366

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-783	Statement Regarding Contributions	SSA-783 - Revised Version.pdf		Yes	No	Fillable Printable
Other-Revised Privacy Act and PRA Statements			SSA-783 - Revised PA and PRA Statements.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,352

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,352	-27,648	30,000
Annual IC Time Burden (Hours)	588	-7,912	8,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-783	SSA-783 - Current Version.pdf	11/16/2020

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