Information Collection

Certificate of Responsibility for Welfare and Care of Child Not In Applicant's Custody

IC 8911 under ICR 202201-0960-001 · OMB 0960-0019.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0019 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-781 Certificate of Responsibility for Welfare and Care of Child Not In Applicant's Custody	Form
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
SSA-781 Certificate of Responsibility for Welfare Care of a Chil SSA-781 - Revised.pdf	Form
SSA-781 - Current.pdf SSA-781 - Current	IC Document

IC Title:

Certificate of Responsibility for Welfare and Care of Child Not In Applicant's Custody

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 404.348-404.349 20 CFR 404.330 20 CFR 404.339-404.341

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-781	Certificate of Responsibility for Welfare Care of a Child Not in Applican'ts Custody	SSA-781 - Revised.pdf		Yes	No	Fillable Printable
Other-Revised PA & PRA Statements			Revised PA & PRA Statements.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 390

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	390	-13,610	14,000
Annual IC Time Burden (Hours)	228	-2,105	2,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-781 - Current	SSA-781 - Current.pdf	05/17/2022

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