Information Collection

Ssa-2935

IC 183776 under ICR 202502-0960-005 · OMB 0960-0189.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-2935 SSA-2935	Form and Instruction
Form SSA-2935 Authorization to the Social Security Administration to Obtain Personal Informaition SSA-2935	Form and Instruction
0960-0189 - Updated PA and PRA Statements.pdf	Other-Revised Privacy Act and PRA St
0960-0189 - Updated PA and PRA Statements.pdf	Other-Revised Privacy Act and PRA St
SSA-2935 Authorization to the Social Security Administration to O SSA-2935 - Revised Version.pdf	Form and Instruction
SSA-2935 Authorization to the Social Security Administration to O SSA-2935 - Revised Version.pdf	Form and Instruction
SSA-2935 - Current Version.pdf Current SSA-2935	IC Document
SSA-2935 - Current Version.pdf Current SSA-2935	IC Document

IC Title:

SSA-2935

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

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 and Instruction	SSA-2935				No		Fillable Fileable
Other-Revised Privacy Act and PRA Statements					No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,350

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,350	0	2,350
Annual IC Time Burden (Hours)	7,246	6,384	862
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-2935		06/27/2025

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

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