Information Collection

Statement Regarding Contributions and Support of Children

IC 34014 under ICR 202411-3220-001 · OMB 3220-0195.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form G-139 Statement Regarding Contributions and Support of Children Statement Regarding Contributions and Support of Children	Form
Form G-139 (Proposed) Statement Regarding Contributions and Support of Children Statement Regarding Contributions and Support of Children	Form
G-139 Statement Regarding Contributions and Support of Childre Form G-139 (07-21) - Current.pdf	Form
G-139 (Proposed) Statement Regarding Contributions and Support of Childre Form G-139 (XX-XX) - Proposed.pdf	Form
SSA-783 (06-2019).pdf Statement Regarding Contribution	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 222.50 20 CFR 222.53 20 CFR 222.55 20 CFR 222.51 20 CFR 222.57 20 CFR 222.56

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	G-139				No		Paper Only
Form	G-139 (Proposed)				No		Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-22, Railroad Retirement, Survivor and Pensioner Benefit System

FR Citation: 79 FR 58874

Number of Respondents: 400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	400	-100	500
Annual IC Time Burden (Hours)	400	-100	500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Statement Regarding Contribution		11/23/2020

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

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