Information Collection

SSA-5665-BK (Electronic)

IC 197497 under ICR 202008-0960-016 · OMB 0960-0646.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0646 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-5665-BK (Elect Teacher Questionnaire SSA-5665-BK (Electronic)	Form and Instruction
Revised PA & PRA Statements - SSA-5665-BK.pdf	Other-Revised PA & PRA Statements
Revised PA & PRA Statements - SSA-5665-BK.pdf	Other-Revised PA & PRA Statements
SSA-5665-BK (Elect Teacher Questionnaire SSA-5665-BK - Revised.pdf	Form and Instruction
SSA-5665-BK (Elect Teacher Questionnaire SSA-5665 - Revised (Clean Copy).pdf	Form and Instruction
SSA-5665-BK - Current.pdf SSA-5665-BK - Current	IC Document
SSA-5665-BK - Current.pdf SSA-5665-BK - Current	IC Document

IC Title:

SSA-5665-BK (Electronic)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.1103(f)

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-5665-BK (Electronic)				Yes	Yes	Fillable Fileable Signable
Other-Revised PA & PRA Statements					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: 246,539

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	246,539	-46,836	293,375
Annual IC Time Burden (Hours)	164,359	-31,224	195,583
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-5665-BK - Current		12/03/2020

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

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