Information Collection

Statement of Employer

IC 43689 under ICR 202505-0960-001 · OMB 0960-0030.

Documents and Forms

Document Name Document Type
Form SSA-7011-F4 Statement of Employer Form
Form SSA-7011-F4 Statement of Employer Statement of Employer Form
SSA-7011-F4 Statement of Employer SSA-7011-F4.pdf Form
SSA-7011-F4 Statement of Employer SSA-7011-F4.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Employer	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 404.801-404.803

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-7011-F4	Statement of Employer	SSA-7011-F4.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 750	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	750	250	500
Annual IC Time Burden (Hours)	750	250	500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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

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