OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Ssa-1709

IC 43695 under ICR 202104-0960-009 · OMB 0960-0098.

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

View Information Collection (IC)

SSA-1709
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 404.408(e)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form SSA-1709 Request for Worker's Compensation/Public Disability Benefit Information SSA-1709 - Revised.pdf Yes Yes Fillable Fileable Signable
Other-Revised PA and PRA Statements Revised PA & PRA Statements.pdf Yes Yes Fillable Fileable Signable

Income Security General Retirement and Disability

 

120,000 0
   
Individuals or Households
 
   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 120,000 0 0 0 0 120,000
Annual IC Time Burden (Hours) 30,000 0 0 0 0 30,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SSA-1709 - Current SSA-1709 - Current.pdf 09/02/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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