Information Collection

Statement of Care and Responsibility for Beneficiary

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Form	SSA-788	No	Fillable Printable
Other-Paper Reduction Act Statement revised		No	Paper Only
Other-Privacy Act Statement (revised)		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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
SSA-788 - Current		08/24/2021

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].