Information Collection

Credit Card Payment Form

IC 9686 under ICR 202111-0960-005 · OMB 0960-0648.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1414 Credit Card Payment Form	Form
Revised PA & PRA Statements.pdf	Other-Revised PA and PRA Statements
SSA-1414 Credit Card Payment Form SSA-1414 (revised).pdf	Form
SSA-1414 (current).pdf SSA-1414 - Current	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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
Form	SSA-1414	Credit Card Payment Form	SSA-1414 (revised).pdf		Yes	No	Fillable Printable
Other-Revised PA and PRA Statements			Revised PA & PRA Statements.pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 6,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	6,000	6,000
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-1414 - Current	SSA-1414 (current).pdf	11/15/2021

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