Information Collection

Ssa-2854

IC 9375 under ICR 202012-0960-011 · OMB 0960-0481.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0481 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-2854 SSA-2854	Form
Form SSA-2854 Statement of Funds YOu Provided to Another SSA-2854	Form
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
SSA-2854 Statement of Funds YOu Provided to Another SSA-2854 - Revised.pdf	Form
SSA-2854 Statement of Funds YOu Provided to Another SSA-2854 - Revised.pdf	Form
SSA-2854 - Current.pdf Current SSA-2854	IC Document
SSA-2854 - Current.pdf Current SSA-2854	IC Document

IC Title:

SSA-2854

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 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	SSA-2854				No		Fillable Printable
Other-Revised PA & PRA Statements					No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20,000

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	20,000	0	20,000
Annual IC Time Burden (Hours)	23,000	19,667	3,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-2854		03/16/2021

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

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