Information Collection

SSA-821-BK - Electronic

IC 273070 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-APP SSA-821-BK - Electronic	Form
Form SSA-821-APP Work Activity Report – Employee SSA-821-BK - Electronic	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-APP Work Activity Report – Employee SSA-821-APP - Screen Package.pdf	Form
SSA-821-APP Work Activity Report – Employee SSA-821-APP - Screen Package.pdf	Form

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 404.1584-1593 20 CFR 404.1571-1576 20 CFR 416.971-976 20 CFR 404.1520(b)

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-APP			www.ssa.gov	Yes	No	Fillable Fileable Signable
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: 25,320

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	25,320	25,320
Annual IC Time Burden (Hours)	25,320	25,320
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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