Information Collection

Personal Interview (SSA Field Office)

IC 195110 under ICR 202010-0960-002 · OMB 0960-0784.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
IRMAA Screens.pdf	Other-Intranet Screens
IRMAA Screens.pdf	Other-Intranet Screens
0784 PRA (revised).pdf	Other-Revised Privacy Act Statement
0784 PRA (revised).pdf	Other-Revised Privacy Act Statement
0784 Privacy Act Statement (revised).pdf	Other-0784 Privacy Act Statement
0784 Privacy Act Statement (revised).pdf	Other-0784 Privacy Act Statement

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 418.2255 20 CFR 418.1265 20 CFR 418.2265 20 CFR 418.1255 20 CFR 418.2205 20 CFR 418.1205

Information Collection Instruments:

table that charts list of instruments
Document Type	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Intranet Screens	Yes	Yes	Fillable Fileable Signable
Other-Revised Privacy Act Statement	Yes	Yes	Printable Only
Other-0784 Privacy Act Statement	Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 178,840

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	178,840	38,462	140,378
Annual IC Time Burden (Hours)	250,376	180,187	70,189
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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