Information Collection

Modified Benefit Formula Questionnaire

IC 9252 under ICR 202503-0960-001 · OMB 0960-0395.

Documents and Forms

Document Name Document Type
Form SSA-150 Modified Benefit Formula Questionnaire Form
CCE Screen Package SSA-150.pdf Other-Internet Screens
CCE Screen Package SSA-150.pdf Other-Internet Screens
SSA-150 Modified Benefit Formula Questionnaire SSA-150 (revised).pdf Form
SSA-150 Modified Benefit Formula Questionnaire SSA-150 (revised).pdf Form
SSA-150 (current).pdf Modified Benefit Formula Questionnaire IC Document
SSA-150 (current).pdf Modified Benefit Formula Questionnaire IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Modified Benefit Formula Questionnaire	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-150	Modified Benefit Formula Questionnaire	SSA-150 (revised).pdf		Yes	No	Fillable Printable
Other-Internet Screens			CCE Screen Package SSA-150.pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 21,540	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

	Approved	Previously Approved
Annual Number of Responses for this IC	21,540	21,540
Annual IC Time Burden (Hours)	28,361	28,361
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Modified Benefit Formula Questionnaire	SSA-150 (current).pdf	03/14/2025

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