Information Collection

f) 20 CFR 411.575 - Requesting EN Payments - SSA-1391; SSA-1398

IC 184462 under ICR 202403-0960-004 · OMB 0960-0644.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1391 f) 20 CFR 411.575 - Requesting EN Payments - SSA-1391; SSA-1398	Form and Instruction
Form SSA-1391 Employment Network Payment Request Form f) 20 CFR 411.575 - Requesting EN Payments - SSA-1391; SSA-1398	Form and Instruction
Form SSA-1389 EN Services Certification Statement (For Use with Phase 1 Milestone 4 Request) f) 20 CFR 411.575 - Requesting EN Payments - SSA-1391; SSA-1398	Form and Instruction
SSA-1391 Employment Network Payment Request Form SSA-1391 (revised).pdf	Form and Instruction
SSA-1391 Employment Network Payment Request Form SSA-1391 (revised).pdf	Form and Instruction
SSA-1389 EN Services Certification Statement (For Use with Phase SSA-1389 EN Certification of Services (revised).pdf	Form and Instruction
SSA-1389 EN Services Certification Statement (For Use with Phase SSA-1389 EN Certification of Services (revised).pdf	Form and Instruction
SSA-1398 - Current Version.pdf Removed Form SSA-1398	IC Document
SSA-1398 - Current Version.pdf Removed Form SSA-1398	IC Document
SSA-1399 - Current Version.pdf Removed Form SSA-1399	IC Document
SSA-1399 - Current Version.pdf Removed Form SSA-1399	IC Document
SSA-1389 EN Certification of Services (current).pdf SSA-1389 EN Certification of Services	IC Document
SSA-1389 EN Certification of Services (current).pdf SSA-1389 EN Certification of Services	IC Document
SSA-1391 (current).pdf Current SSA-1391	IC Document
SSA-1391 (current).pdf Current SSA-1391	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 411.575

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-1391				No		Paper Only
Form and Instruction	SSA-1389				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,704

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	1,704	1,704
Annual IC Time Burden (Hours)	1,136	1,136
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Removed Form SSA-1398		01/15/2021
Removed Form SSA-1399		01/15/2021
SSA-1389 EN Certification of Services		01/18/2024
Current SSA-1391		03/25/2024

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].