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Federal forms, ICRs, and supporting documents

Information Collection

Agency/Employer Government Pension Offset Questionnaire

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

Documents and Forms
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Document Type
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Other-Privacy Act Statement
Other-Privacy Act Statement
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Form
IC Document
IC Document
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Agency/Employer Government Pension Offset Questionnaire
 
No Modified
 
Voluntary
 
20 CFR 404.408(a)

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

Income Security General Retirement and Disability

 

2,911 0
   
State, Local, and Tribal Governments
 
   0 %

  Approved 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 2,911 0 0 0 0 2,911
Annual IC Time Burden (Hours) 485 0 0 339 0 146
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.