Information Collection

Statement of Income and Resources

IC 9097 under ICR 202011-0960-002 · OMB 0960-0124.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8010 Statement of Income and Resources	Form
Form SSA-8010 Statement of Income and Resources (Screens) Statement of Income and Resources	Form
Form SSA-8010-BK Statement of Income and Resources Statement of Income and Resources	Form
0124 PRA Statement (revised).pdf	Other-Revised PRA Statement
0124 PRA Statement (revised).pdf	Other-Revised PRA Statement
SSA-8010 Statement of Income and Resources (Screens) 0124 SSI claims screens.pdf	Form
SSA-8010 Statement of Income and Resources (Screens) 0124 SSI claims screens.pdf	Form
SSA-8010-BK Statement of Income and Resources SSA-8010-BK (revised).pdf	Form
SSA-8010-BK Statement of Income and Resources SSA-8010-BK (revised).pdf	Form
SSA-8010-BK (current).pdf SSA-8010-BK - Current	IC Document
SSA-8010-BK (current).pdf SSA-8010-BK - Current	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.704 20 CFR 416.207 20 CFR 416.708 20 CFR 416.301-416.310

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-8010	Yes	Yes	Fillable Fileable Signable
Form	SSA-8010-BK	No		Paper Only
Other-Revised PRA Statement		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,916,720

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 97 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,916,720	1,575,720	341,000
Annual IC Time Burden (Hours)	1,916,720	1,768,953	147,767
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-8010-BK - Current		11/06/2020

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

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