SSA-120 Internet Version Application for access to SSA Systems

Application for Access to SSA Systems

Documents and Forms

Document Name Document Type
Electronic SSA-120 - Revised.pdf Other-Screens
Privacy Act Statement 0791.docx Other-Privacy Act Statement (revised
Electronic SSA-120 (current).pdf Electronic SSA-120 - Current IC Document

Information Collection (IC) Details

IC Title:	SSA-120 Internet Version Application for access to SSA Systems	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 26 CFR 31.6109-1 26 CFR 401.45 26 CFR 31.6011(b)2

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screens			Electronic SSA-120 - Revised.pdf		Yes	Yes	Fillable Fileable Signable
Other-Privacy Act Statement (revised)			Privacy Act Statement 0791.docx		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,482	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,482	0	1,482
Annual IC Time Burden (Hours)	49	12	37
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Electronic SSA-120 - Current	Electronic SSA-120 (current).pdf	04/28/2021

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