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Federal forms, ICRs, and supporting documents

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

View Information Collection (IC)

Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form
 
No Modified
 
Voluntary
 
20 CFR 404.502 - 404.521

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction SSA-3105 Important Information About Your Appeal, Waiver Rights, and Repayment Options SSA-3105 - Revised.pdf Yes No Fillable Printable
Other-Revised PA & PRA Statements Revised PA & PRA Statements.pdf Yes No Fillable Printable

Income Security General Retirement and Disability

 

500,000 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 500,000 0 0 0 0 500,000
Annual IC Time Burden (Hours) 375,000 0 0 250,000 0 125,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SSA-3105 - Current SSA-3105 - Current.pdf 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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