Information Collection

Statement of Employer

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

Documents and Forms

Documents and forms in this information collection
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

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 404.801-404.803

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	SSA-7011-F4				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 %

table that charts list of burden
	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

table that charts IC Documents
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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].