Information Collection

Agency/Employer Government Pension Offset Questionnaire

IC 9355 under ICR 202209-0960-004 · OMB 0960-0470.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L4163 Agency/Employer Government Pension Offset Questionnaire	Form
SSA-L4163 - Revised Privacy Act Statement.pdf	Other-Privacy Act Statement
SSA-L4163 - Revised Privacy Act Statement.pdf	Other-Privacy Act Statement
SSA-L4163 Agency/Employer Government Pension Offset Questionnaire SSA-4162 (revised).pdf	Form
SSA-L4163 Agency/Employer Government Pension Offset Questionnaire SSA-L4163 (revised).pdf	Form
SSA-4162 (current).pdf SSA-L4163 - Current	IC Document
SSA-L4163 (current).pdf SSA-L4163 - Current	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.408(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
Form	SSA-L4163	Agency/Employer Government Pension Offset Questionnaire	SSA-L4163 (revised).pdf		No		Paper Only
Other-Privacy Act Statement			SSA-L4163 - Revised Privacy Act Statement.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,911

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
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,911	0	2,911
Annual IC Time Burden (Hours)	485	339	146
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-L4163 - Current	SSA-L4163 (current).pdf	05/03/2023

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