Information Collection

Statement of Self-Employment Income

IC 43691 under ICR 202411-0960-014 · OMB 0960-0046.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-766 Statement of Self-Employment Income	Form
Form SSA-766 Statement of Self-Employment Income Statement of Self-Employment Income	Form
PRA 0046 (revised).docx	Other-Revised Paperwork Reduction Ac
PRA 0046 (revised).docx	Other-Revised Paperwork Reduction Ac
PA Statement 0046 (revised).docx	Other-Revised Privacy Act
PA Statement 0046 (revised).docx	Other-Revised Privacy Act
SSA-766 Statement of Self-Employment Income SSA-766.(revised) PRA PA statement Signature removal Perjury.pdf	Form
SSA-766 Statement of Self-Employment Income SSA-766.(revised) PRA PA statement Signature removal Perjury.pdf	Form
SSA-766 (current).pdf Statement of Self-Employment Income	IC Document
SSA-766 (current).pdf Statement of Self-Employment Income	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.610 20 CFR 404.110 20 CFR 404.1096 20 CFR 404.611 20 CFR 404.101 20 CFR 422.405

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-766	Yes	No	Fillable Printable
Other-Revised Paperwork Reduction Act		Yes	No	Printable Only
Other-Revised Privacy Act		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: 910

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	Previously Approved
Annual Number of Responses for this IC	910	910
Annual IC Time Burden (Hours)	76	76
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Statement of Self-Employment Income		11/27/2024

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

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