Information Collection

Employee Non-Covered Service Pension Questionnaire

IC 33954 under ICR 202012-3220-004 · OMB 3220-0154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form G-209 Employee Non-Covered Service Pension Questionnaire	Form and Instruction
G-209 Employee Non-Covered Service Pension Questionnaire Form G-209 (05-17).pdf	Form and Instruction
G-209 Employee Non-Covered Service Pension Questionnaire Form G-209 (05-17).pdf	Form and Instruction
Form SSA-150 (10-2014).pdf Modified Benefit Formula Questionnaire	IC Document
Form SSA-150 (10-2014).pdf Modified Benefit Formula Questionnaire	IC Document
Form RL-1 (04-07).pdf Transmittal Letter	IC Document
Form RL-1 (04-07).pdf Transmittal Letter	IC Document

IC Title:

Employee Non-Covered Service Pension Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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	G-209	Employee Non-Covered Service Pension Questionnaire	Form G-209 (05-17).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit Sytem

FR Citation: 79 FR 58874

Number of Respondents: 150

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	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	14	14
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Modified Benefit Formula Questionnaire	Form SSA-150 (10-2014).pdf	12/09/2020
Transmittal Letter	Form RL-1 (04-07).pdf	12/10/2020

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