Information Collection

Modified Benefit Formula Questionnaire

IC 9252 under ICR 202410-0960-016 · OMB 0960-0395.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0395 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-150 Modified Benefit Formula Questionnaire	Form
Form SSA-150 Modified Benefit Formula Questionnaire Modified Benefit Formula Questionnaire	Form
CCE Screen Package SSA-150.pdf	Other-Internet Screens
CCE Screen Package SSA-150.pdf	Other-Internet Screens
SSA-150 Modified Benefit Formula Questionnaire SSA-150 Revised.pdf	Form
SSA-150 Modified Benefit Formula Questionnaire SSA-150 Revised.pdf	Form
SSA-150 Current.pdf Modified Benefit Formula Questionnaire	IC Document
SSA-150 Current.pdf Modified Benefit Formula Questionnaire	IC Document

IC Title:

Modified Benefit Formula Questionnaire

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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-150				Yes	No	Fillable Printable
Other-Internet Screens					No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 21,540

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	21,540	21,540
Annual IC Time Burden (Hours)	28,361	28,361
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Modified Benefit Formula Questionnaire		10/23/2024

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

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