Information Collection

Continuation of SSI Benefits for the Temporarily Institutionalized - Certification of Period and Need to Maintain Home - Statement from other Respondents

IC 9422 under ICR 202105-0960-001 · OMB 0960-0516.

Documents and Forms

Document Name Document Type
Form SSA-186 Temporary Institutionalization Statement to Maintain Household and Physician Certification Continuation of SSI Benefits for the Temporarily Institutionalized - Certification of Period and Need to Maintain Home - Statement from other Respondents Form
SSI Claims System Institution Residence Pages - Screen Shots.pdf Other-SSI Claims System Screens
SSI Claims System Institution Residence Pages - Screen Shots.pdf Other-SSI Claims System Screens
SSA-186 Temporary Institutionalization Statement to Maintain Hou SSA-186.pdf Form
SSA-186 Temporary Institutionalization Statement to Maintain Hou SSA-186.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Continuation of SSI Benefits for the Temporarily Institutionalized - Certification of Period and Need to Maintain Home - Statement from other Respondents	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 416.212(b)(1)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-SSI Claims System Screens			SSI Claims System Institution Residence Pages - Screen Shots.pdf		Yes	Yes	Fillable Fileable
Form	SSA-186	Temporary Institutionalization Statement to Maintain Household and Physician Certification	SSA-186.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 26,793	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	26,793	-33,207	60,000
Annual IC Time Burden (Hours)	15,183	10,183	5,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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

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