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Federal forms, ICRs, and supporting documents

Information Collection

Certificate of Responsibility for Welfare and Care of Child Not In Applicant's Custody

IC 8911 under ICR 202603-0960-005 · OMB 0960-0019.

Documents and Forms
Document Name
Document Type
Form
Other-Revised Privacy Act Statement
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Certificate of Responsibility for Welfare and Care of Child Not In Applicant's Custody
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 404.348-404.349 20 CFR 404.330 20 CFR 404.339-404.341

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form SSA-781 Certificate of Responsibility for Welfare Care of a Child Not in Applican'ts Custody SSA-781 - Revised Version.pdf Yes No Fillable Printable
Other-Revised Privacy Act Statement SSA-781 - Revised PA Statement.pdf Yes No Printable Only

Income Security General Retirement and Disability

 

478 0
   
Individuals or Households
 
   20 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 478 0 0 88 0 390
Annual IC Time Burden (Hours) 279 0 0 51 0 228
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SSA-781 - Current Version SSA-781 - Current Version.pdf 04/17/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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