Information Collection

SSA-821-BK - Returned Via Mail

IC 273069 under ICR 202409-0960-008 · OMB 0960-0059.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-821-BK SSA-821-BK - Returned Via Mail	Form
Form SSA-821-BK Work Activity Report – Employee SSA-821-BK - Returned Via Mail	Form
SSA-821 - Revised PA & PRA Statements.pdf	Other-Revised Privacy Act and PRA St
SSA-821 - Revised PA & PRA Statements.pdf	Other-Revised Privacy Act and PRA St
SSA-821-BK Work Activity Report – Employee SSA-821-BK (revised).pdf	Form
SSA-821-BK Work Activity Report – Employee SSA-821-BK (revised).pdf	Form
SSA-892-BK (Current).pdf SSA-821 - Current Version	IC Document
SSA-892-BK (Current).pdf SSA-821 - Current Version	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 404.1571-1576 20 CFR 416.971-976 20 CFR 404.1520(b) 20 CFR 404.1584-1593

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-821-BK			www.ssa.gov	Yes	No	Fillable Printable
Other-Revised Privacy Act and PRA Statements					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: 192,990

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	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	192,990	192,990
Annual IC Time Burden (Hours)	176,908	176,908
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-821 - Current Version		12/16/2024

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

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