Information Collection

a) 20 CFR 411.140(d)(3); 411.150(b)(3); 411.325(a) - SSA-1365 State Agency Ticket Assignment Form

IC 201837 under ICR 202403-0960-004 · OMB 0960-0644.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
DemoDeck.pptx	Other-screens
DemoDeck.pptx	Other-screens

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 411.150(b)(3) 20 CFR 411.140(d)(3) 20 CFR 411.325(a)

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-screens					Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 948

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	948	948
Annual IC Time Burden (Hours)	237	237
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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