Information Collection

0960-0229 - SSA-8000-BK (Paper Version)

IC 265516 under ICR 202402-0960-006 · OMB 0960-0838.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-8000-BK 0960-0229 - SSA-8000-BK (Paper Version)	Form and Instruction
Form SSA-8000-BK Application for Supplemental Security Income 0960-0229 - SSA-8000-BK (Paper Version)	Form and Instruction
Form SSA-8000-BK (effec Application for Supplemental Security Income 0960-0229 - SSA-8000-BK (Paper Version)	Form and Instruction
SSA-8000-BK Application for Supplemental Security Income SSA-8000-BK - Revised Version.pdf	Form and Instruction
SSA-8000-BK Application for Supplemental Security Income SSA-8000-BK - Revised Version.pdf	Form and Instruction
SSA-8000-BK (effec Application for Supplemental Security Income Form SSA-8000-BK - Revisions effective 9-30-2024.pdf	Form and Instruction
SSA-8000-BK (effec Application for Supplemental Security Income Form SSA-8000-BK - Revisions effective 9-30-2024.pdf	Form and Instruction
SSA-8000-BK - Current Version.pdf Current SSA-8000-BK	IC Document
SSA-8000-BK - Current Version.pdf Current SSA-8000-BK	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1102-416.1104 20 CFR 416.1121 20 CFR 416.1130 20 CFR 416.1201(a) 20 CFR 416.202

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	SSA-8000-BK				No		Paper Only
Form and Instruction	SSA-8000-BK (effective on 9/30/24)				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 705

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 New Statute
Annual Number of Responses for this IC	705	705
Annual IC Time Burden (Hours)	705	705
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-8000-BK		02/21/2024

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

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