Information Collection

Pension Benefit Statement

IC 242407 under ICR 202108-1210-004 · OMB 1210-0166.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1210-0166 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Lifetime APPENDIX I-II-07-21-2020-clean.docx	Other-Model
Lifetime APPENDIX I-II-07-21-2020-clean.docx	Other-Model

IC Title:

Pension Benefit Statement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 29 CFR 2520.105-3

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
Other-Model			Lifetime APPENDIX I-II-07-21-2020-clean.docx		Yes	Yes	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 721,876

Number of Respondents for Small Entity: 629,396

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 93 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	410,933,333	410,933,333
Annual IC Time Burden (Hours)	19,675	19,675
Annual IC Cost Burden (Dollars)	498,958,393	498,958,393

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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