Information Collection

SSA-L3365, Request for Employee Information

IC 178761 under ICR 202411-0960-017 · OMB 0960-0508.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-L3365 SSA-L3365, Request for Employee Information	Form
Form SSA-L3365 Request for Employee Information SSA-L3365, Request for Employee Information	Form
SSA-L3365 Request for Employee Information SSA-L3365 - Revised.pdf	Form
SSA-L3365 Request for Employee Information SSA-L3365 - Revised.pdf	Form
SSA-L3365 - Current.pdf SSA-L3365 - Current	IC Document
SSA-L3365 - Current.pdf SSA-L3365 - Current	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 422.120

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-L3365				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1

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	1	1
Annual IC Time Burden (Hours)	0	0
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-L3365 - Current		04/01/2020

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

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