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Federal forms, ICRs, and supporting documents

Information Collection

State Agency Ticket Assignment Form (SSA-1365)

IC 218036 under ICR 202101-0960-002 · OMB 0960-0644.

Documents and Forms
Document Name
Document Type
Form
Other-Revised PA and PRA Statements
Other-Revised PA and PRA Statements
Form
Form
IC Document
IC Document
Information Collection (IC) Details

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State Agency Ticket Assignment Form (SSA-1365)
 
No Unchanged
 
Mandatory
 
20 CFR 411.325(a) 20 CFR 411.140(d)(3), 411.150(b)(3)

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

Income Security General Retirement and Disability

 

948 0
   
State, Local, and Tribal Governments
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 948 0 0 0 0 948
Annual IC Time Burden (Hours) 237 0 0 0 0 237
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.