Information Collection

Self-Employment Questionnaire

IC 33934 under ICR 202308-3220-004 · OMB 3220-0138.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AA-4 (06-23) Self-Employment Questionnaire	Form and Instruction
AA-4 (06-23) Self-Employment and Substantial Service Questionnaire Form AA-4 (06-23).pdf	Form and Instruction
AA-4 (06-23) Self-Employment and Substantial Service Questionnaire Form AA-4 (06-23).pdf	Form and Instruction
Form AA-1 (01-18).pdf Application for Employee Annuity	IC Document
Form AA-1 (01-18).pdf Application for Employee Annuity	IC Document
Form AA-3 (07-17).pdf Application for Spouse/Divorced Spouse Annuity	IC Document
Form AA-3 (07-17).pdf Application for Spouse/Divorced Spouse Annuity	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 216.11-16

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	AA-4 (06-23)	Self-Employment and Substantial Service Questionnaire	Form AA-4 (06-23).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System

FR Citation: 79 FR 58874

Number of Respondents: 1,167

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,167	567	600
Annual IC Time Burden (Hours)	807	392	415
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Application for Employee Annuity	Form AA-1 (01-18).pdf	05/20/2020
Application for Spouse/Divorced Spouse Annuity	Form AA-3 (07-17).pdf	05/12/2020

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