Information Collection

Discrimination Complaint Form

IC 9560 under ICR 202601-0960-007 · OMB 0960-0585.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-437-BK Discrimination Complaint Form Discrimination Complaint Form	Form and Instruction
Revised PAS.docx	Other-Revised PA Statement
SSA-437-BK Discrimination Complaint Form SSA-437 (REVISED).pdf	Form and Instruction
ssa-437 (current).pdf SSA-437-BK - Current	IC Document

IC Title:

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-437-BK				Yes	No	Fillable Fileable
Other-Revised PA Statement					No		Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	600	100	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
SSA-437-BK - Current		04/24/2026

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

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