Information Collection

Preparing Causality Statements

IC 45274 under ICR 202201-0960-002 · OMB 0960-0310.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0310 can be found here:

Documents and Forms

Document Name Document Type
Preparing Causality Statements.pdf Other-Causality Statements
SSA-199 - Portal Screens.pdf Other-Portal Screens

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Preparing Causality Statements	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 404.2101(a) 20 CFR 416.2221(a) 20 CFR 404.2121(a) 20 CFR 416.2201(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Causality Statements			Preparing Causality Statements.pdf		No		Paper Only
Other-Portal Screens			SSA-199 - Portal Screens.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 77	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	193	-7	200
Annual IC Time Burden (Hours)	322	-11	333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.