Information Collection

Response to Notice of Revised Determination

IC 9225 under ICR 202112-0960-005 · OMB 0960-0347.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0347 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-765 Response to Notice of Revised Determination	Form
SSA-765 - Updated PA Statement.pdf	Other-Revised Privacy Act Statement
0347 PRA (revised).docx	Other-Paperwork Reduction Act (revis
SSA-765 Response to Notice of Revised Determination SSA-765 (Revised).pdf	Form
SSA-765 (Current).pdf Current SSA-765	IC Document

IC Title:

Response to Notice of Revised Determination

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 416.1413-.1414 20 CFR 416.1492(d) 20 CFR 404.992(b) 20 CFR 404.913-.914

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-765	Response to Notice of Revised Determination	SSA-765 (Revised).pdf	No	Paper Only
Other-Revised Privacy Act Statement			SSA-765 - Updated PA Statement.pdf	No	Paper Only
Other-Paperwork Reduction Act (revised)			0347 PRA (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: 1,925

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,925	0	1,925
Annual IC Time Burden (Hours)	2,695	1,732	963
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-765	SSA-765 (Current).pdf	01/26/2022

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