Information Collection

Statement of Claimant or Other Person (Telephone interviews)

IC 250002 under ICR 202502-0960-016 · OMB 0960-0045.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Revised CCE Screen package for SSA-795 - 5-5-22.pdf	Other-SSI Claim System Remarks Scree
Revised CCE Screen package for SSA-795 - 5-5-22.pdf	Other-SSI Claim System Remarks Scree
SSA-795 screen package (current).docx SSI Claim System Remarks Screen	IC Document
SSA-795 screen package (current).docx SSI Claim System Remarks Screen	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 404.702 20 CFR 416.570

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
Other-SSI Claim System Remarks Screen					Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 22,516

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	22,516	-2,067	24,583
Annual IC Time Burden (Hours)	6,755	609	6,146
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSI Claim System Remarks Screen		11/02/2021

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

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