Information Collection

20 CFR 404.1512, 404.1740(c)(4), 416.912, and 416.1540(c)(4)

IC 237195 under ICR 202108-0960-009 · OMB 0960-0710.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0710 can be found here:

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Information Collection (IC) Details

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IC Title:	20 CFR 404.1512, 404.1740(c)(4), 416.912, and 416.1540(c)(4)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1512 20 CFR 404.1740(c)(4) 20 CFR 416.912 20 CFR 416.1540(c)(4)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

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