Information Collection

SSA-L4002, Request for Employer Information

IC 178763 under ICR 202411-0960-017 · OMB 0960-0508.

Documents and Forms

Document Name Document Type
Form SSA-L4002 SSA-L4002, Request for Employer Information Form
SSA-L4002 Request for Employer Information SSA-L4002 - Revised.pdf Form
SSA-L4002 - Current.pdf SSA-L4002 - Current IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SSA-L4002, Request for Employer Information	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-L4002	Request for Employer Information	SSA-L4002 - Revised.pdf		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: Private Sector	Private Sector: Farms, Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1	0	1
Annual IC Time Burden (Hours)	0	0	0
Annual IC Cost Burden (Dollars)	31	31	0

Documents for IC

Title	Document	Date Uploaded
SSA-L4002 - Current	SSA-L4002 - Current.pdf	04/01/2020

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