Information Collection

Ssa-9314

IC 182005 under ICR 202010-0960-008 · OMB 0960-0707.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0707 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-9314 SSA-9314	Form and Instruction
SSA-9314 Notice of Quality Review Acknowledgement Form for those SSA-9314(revised).pdf	Form and Instruction
SSA-9314 (current).pdf Current SSA-9314	IC Document

IC Title:

SSA-9314

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(b)(5) (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-9314	Notice of Quality Review Acknowledgement Form for those without Phones	SSA-9314(revised).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

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	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-9314	SSA-9314 (current).pdf	01/28/2021

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