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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Preparing Causality Statements.pdf	Other-Causality Statements
SSA-199 - Portal Screens.pdf	Other-Portal Screens

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:

table that charts list of 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 %

table that charts list of burden
	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

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.