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Federal forms, ICRs, and supporting documents

Information Collection

Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111)

IC 180150 under ICR 202204-0960-006 · OMB 0960-0759.

Documents and Forms
Document Name
Document Type
Form
Other-Revised PA & PRA Statements
Form
IC Document
Information Collection (IC) Details

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Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits (SSA-4111)
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 404.335

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form SSA-4111 Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits SSA-4111 - Revised.pdf Yes No Fillable Printable
Other-Revised PA & PRA Statements Revised PA & PRA Statements.pdf Yes No Fillable Printable

Income Security General Retirement and Disability

 

30,000 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 30,000 0 0 0 0 30,000
Annual IC Time Burden (Hours) 1,000 0 0 0 0 1,000
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SSA-4111 - Current SSA-4111 - Current.pdf 08/17/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.