Information Collection

Ssa-4659

IC 183268 under ICR 202210-0960-002 · OMB 0960-0189.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0189 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4659 SSA-4659	Form
0960-0189 Privacy Act Statement (revised).docx	Other-Privacy Act Statement (revised
0960-0189 Privacy Act Statement (revised).docx	Other-Privacy Act Statement (revised
SSA-4659 Stewardship Annual Earnings Test Workbook SSA-4659 (revised).pdf	Form
SSA-4659 Stewardship Annual Earnings Test Workbook SSA-4659 (revised).pdf	Form
SSA-4659 (current).pdf SSA-4659 - Current	IC Document
SSA-4659 (current).pdf SSA-4659 - Current	IC Document

IC Title:

SSA-4659

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	SSA-4659	Stewardship Annual Earnings Test Workbook	SSA-4659 (revised).pdf		No		Fillable Printable
Other-Privacy Act Statement (revised)			0960-0189 Privacy Act Statement (revised).docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 325

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	Previously Approved
Annual Number of Responses for this IC	325	325
Annual IC Time Burden (Hours)	146	146
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-4659 - Current	SSA-4659 (current).pdf	10/12/2022

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