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

Documents and forms in this information collection
Document Name	Document Type
Form SSA-781 Certificate of Responsibility for Welfare Care of a Child Not in Applican'ts Custody Certificate of Responsibility for Welfare and Care of Child Not In Applicant's Custody	Form
SSA-781 - Revised PA Statement.pdf	Other-Revised Privacy Act Statement
SSA-781 Certificate of Responsibility for Welfare Care of a Chil SSA-781 - Revised Version.pdf	Form
SSA-781 - Current Version.pdf SSA-781 - Current Version	IC Document

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 404.348-404.349 20 CFR 404.330 20 CFR 404.339-404.341

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-781				Yes	No	Fillable Printable
Other-Revised Privacy Act Statement					Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 478

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	478	88	390
Annual IC Time Burden (Hours)	279	51	228
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-781 - Current Version		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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