Ssa-1709

Request for Workers' Compensation/Public Disability Benefit Information

Documents and Forms

Document Name Document Type
Form SSA-1709 SSA-1709 Form
Revised PA & PRA Statements.pdf Other-Revised PA and PRA Statements
SSA-1709 Request for Worker's Compensation/Public Disability Bene SSA-1709 - Revised.pdf Form
SSA-1709 - Current.pdf SSA-1709 - Current IC Document

Information Collection (IC) Details

IC Title:	SSA-1709	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.408(e)

Information Collection Instruments:

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

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	120,000	120,000
Annual IC Time Burden (Hours)	30,000	30,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.