State Agency Ticket Assignment Form (SSA-1365)

The Ticket to Work and Self-Sufficiency Program

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form SSA-1365 State Agency Ticket Assignment Form (SSA-1365) Form
SSA-1365 - Revised PA & PRA Statements.pdf Other-Revised PA and PRA Statements
SSA-1365 - Revised PA & PRA Statements.pdf Other-Revised PA and PRA Statements
SSA-1365 State Agency Ticket Assignment Form SSA-1365 - Revised.pdf Form
SSA-1365 State Agency Ticket Assignment Form SSA-1365 - Revised.pdf Form
SSA-1365 - Current.pdf SSA-1365 - Current IC Document
SSA-1365 - Current.pdf SSA-1365 - Current IC Document

Information Collection (IC) Details

IC Title:	State Agency Ticket Assignment Form (SSA-1365)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 411.325(a) 20 CFR 411.140(d)(3), 411.150(b)(3)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-1365	State Agency Ticket Assignment Form	SSA-1365 - Revised.pdf		No		Fillable Printable
Other-Revised PA and PRA Statements			SSA-1365 - Revised PA & PRA Statements.pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 948	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	948	948
Annual IC Time Burden (Hours)	237	237
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-1365 - Current	SSA-1365 - Current.pdf	11/07/2018

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