Information Collection

Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form

IC 191893 under ICR 202108-0960-002 · OMB 0960-0779.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-3105 Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form	Form and Instruction
Form SSA-3105 Important Information About Your Appeal, Waiver Rights, and Repayment Options Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form	Form and Instruction
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
SSA-3105 Important Information About Your Appeal, Waiver Rights, SSA-3105 - Revised.pdf	Form and Instruction
SSA-3105 Important Information About Your Appeal, Waiver Rights, SSA-3105 - Revised.pdf	Form and Instruction
SSA-3105 - Current.pdf SSA-3105 - Current	IC Document
SSA-3105 - Current.pdf SSA-3105 - Current	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.502 - 404.521

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3105				Yes	No	Fillable Printable
Other-Revised PA & PRA Statements					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: 500,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	500,000	0	500,000
Annual IC Time Burden (Hours)	375,000	250,000	125,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-3105 - Current		01/12/2022

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

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