Information Collection

f) 20 CFR 411.575 - SSA-1391; SSA-1389

IC 184462 under ICR 202101-0960-002 · OMB 0960-0644.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0644 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1391 Employment Network Payment Request Form f) 20 CFR 411.575 - SSA-1391; SSA-1389	Form and Instruction
Form SSA-1389 EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request) f) 20 CFR 411.575 - SSA-1391; SSA-1389	Form and Instruction
SSA-1389 - Revised PA & PRA Statements.pdf	Other-Revised PA and PRA Statements
SSA-1389 - Revised PA & PRA Statements.pdf	Other-Revised PA and PRA Statements
SSA-1391 - Revised PA & PRA Statements.pdf	Other-Revised PA and PRA Statements
SSA-1391 - Revised PA & PRA Statements.pdf	Other-Revised PA and PRA Statements
SSA-1391 Employment Network Payment Request Form SSA-1391 - Revised.pdf	Form and Instruction
SSA-1391 Employment Network Payment Request Form SSA-1391 - Revised.pdf	Form and Instruction
SSA-1389 EN Services Certification Statement (For Use with Phase SSA-1389 - Revised.pdf	Form and Instruction
SSA-1389 EN Services Certification Statement (For Use with Phase SSA-1389 - Revised.pdf	Form and Instruction
SSA-1398 - Current Version.pdf Removed Form SSA-1398	IC Document
SSA-1398 - Current Version.pdf Removed Form SSA-1398	IC Document
SSA-1399 - Current Version.pdf Removed Form SSA-1399	IC Document
SSA-1399 - Current Version.pdf Removed Form SSA-1399	IC Document

IC Title:

f) 20 CFR 411.575 - SSA-1391; SSA-1389

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 411.575

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	SSA-1391	Employment Network Payment Request Form	SSA-1391 - Revised.pdf	No	Paper Only
Form and Instruction	SSA-1389	EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request)	SSA-1389 - Revised.pdf	No	Paper Only
Other-Revised PA and PRA Statements			SSA-1389 - Revised PA & PRA Statements.pdf	No	Paper Only
Other-Revised PA and PRA Statements			SSA-1391 - Revised PA & PRA Statements.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: 2,805

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	2,805	2,805
Annual IC Time Burden (Hours)	1,870	1,870
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Removed Form SSA-1398	SSA-1398 - Current Version.pdf	01/15/2021
Removed Form SSA-1399	SSA-1399 - Current Version.pdf	01/15/2021

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