Information Collection

Ssa-l9785

IC 195825 under ICR 202009-0960-010 · OMB 0960-0369.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L9785 SSA-L9785	Form and Instruction
Form SSA-L9785 Retirement, Survivors and Disability Insurance: Earnings Estimate Form SSA-L9785	Form and Instruction
SSA-L9785 Retirement, Survivors and Disability Insurance: Earnings SSA-9785 - Revised Version.pdf	Form and Instruction
SSA-L9785 Retirement, Survivors and Disability Insurance: Earnings SSA-L9785-SM (Revised - Signature Removal).pdf	Form and Instruction
SSA-9785 - Current Version.pdf Current SSA-9785	IC Document
SSA-9785 - Current Version.pdf Current SSA-9785	IC Document

IC Title:

SSA-L9785

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 404.452-404.455

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-L9785				No		Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 15,870

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15,870	0	15,870
Annual IC Time Burden (Hours)	7,935	5,290	2,645
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-9785		12/08/2020

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

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