Information Collection

Statement of Care and Responsibility for Beneficiary

IC 43697 under ICR 202108-0960-011 · OMB 0960-0109.

Documents and Forms

Document Name Document Type
Form SSA-788 Statement of Care and Responsibility for Beneficiary Form
Form SSA-788 Statement of Care and Responsibility for Beneficiary Statement of Care and Responsibility for Beneficiary Form
0109 Privacy Act Statement (revised).docx Other-Paper Reduction Act Statement
0109 Privacy Act Statement (revised).docx Other-Paper Reduction Act Statement
PRA Statement 0109 (revised).docx Other-Privacy Act Statement (revised
PRA Statement 0109 (revised).docx Other-Privacy Act Statement (revised
SSA-788 Statement of Care and Responsibility for Beneficiary Form SSA-788 (revised).pdf Form
SSA-788 Statement of Care and Responsibility for Beneficiary Form SSA-788 (revised).pdf Form
Form SSA-788 (current).pdf SSA-788 - Current IC Document
Form SSA-788 (current).pdf SSA-788 - Current IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Care and Responsibility for Beneficiary	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 408.620 20 CFR 408.625 20 CFR 404.2020 20 CFR 404.2025 20 CFR 416.625 20 CFR 416.620

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-788	Statement of Care and Responsibility for Beneficiary	Form SSA-788 (revised).pdf	No	Fillable Printable
Other-Paper Reduction Act Statement revised			0109 Privacy Act Statement (revised).docx	No	Paper Only
Other-Privacy Act Statement (revised)			PRA Statement 0109 (revised).docx	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 134,000	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	134,000	4,000	130,000
Annual IC Time Burden (Hours)	22,333	666	21,667
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-788 - Current	Form SSA-788 (current).pdf	08/24/2021

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

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