Information Collection

Discrimination Complaint Form

IC 9560 under ICR 202205-0960-002 · OMB 0960-0585.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0585 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-437-BK Discrimination Complaint Form	Form and Instruction
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
Revised PA & PRA Statements.pdf	Other-Revised PA & PRA Statements
SSA-437-BK Discrimination Complaint Form SSA-437-BK - Revised.pdf	Form and Instruction
SSA-437-BK Discrimination Complaint Form SSA-437-BK - Revised.pdf	Form and Instruction
SSA-437-BK - Current.pdf SSA-437-BK - Current	IC Document
SSA-437-BK - Current.pdf SSA-437-BK - Current	IC Document

IC Title:

Discrimination Complaint Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

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 and Instruction	SSA-437-BK	Discrimination Complaint Form	SSA-437-BK - Revised.pdf		Yes	No	Fillable Fileable
Other-Revised PA & PRA Statements			Revised PA & PRA Statements.pdf		Yes	No	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	500	245	255
Annual IC Time Burden (Hours)	500	245	255
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-437-BK - Current	SSA-437-BK - Current.pdf	09/02/2022

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