Information Collection

f) 20 CFR 411.560 - SSA-1401, Split Payment Situations

IC 190323 under ICR 202403-0960-004 · OMB 0960-0644.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-1401 f) 20 CFR 411.560 - SSA-1401, Split Payment Situations	Form
Form SSA-1401 Employment Network Split Payment Request Form f) 20 CFR 411.560 - SSA-1401, Split Payment Situations	Form
SSA-1401 Employment Network Split Payment Request Form SSA-1401 (revised).pdf	Form
SSA-1401 Employment Network Split Payment Request Form SSA-1401 (revised).pdf	Form
SSA-1401 (current).pdf Current SSA-1401	IC Document
SSA-1401 (current).pdf Current SSA-1401	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 411.560

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-1401	Employment Network Split Payment Request Form	SSA-1401 (revised).pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5

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	5	5
Annual IC Time Burden (Hours)	2	2
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-1401	SSA-1401 (current).pdf	03/25/2024

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