Information Collection

Ssa-9301

IC 9763 under ICR 202306-0960-003 · OMB 0960-0707.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0707 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SSA-9301 (revised version).pdf	Other-Telephone Interview Script
SSA-9301 (current version).pdf SSA-9301 Current Version	IC Document

IC Title:

SSA-9301

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 418(b)(5) (To search for a specific CFR, visit the Code of Federal Regulations.)

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
Other-Telephone Interview Script			SSA-9301 (revised version).pdf	N/A conducted over telephone	No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,500

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	Previously Approved
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	1,750	1,750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-9301 Current Version	SSA-9301 (current version).pdf	06/22/2023

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