Information Collection

State/Local/Tribal Government: Paper SSA-11-BK

IC 186313 under ICR 202604-0960-011 · OMB 0960-0014.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-11-BK Request to be Selected as a Payee State/Local/Tribal Government: Paper SSA-11-BK	Form
SSA-11-BK Request to be Selected as a Payee SSA-11-BK.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 404.2010-404.2055 20 CFR 416.601-416.665

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-11-BK				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 352

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

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	352	2	350
Annual IC Time Burden (Hours)	246	176	70
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.

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