Information Collection

Self-Employment Questionnaire

IC 33934 under ICR 202606-3220-002 · OMB 3220-0138.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form AA-4 (06-23) Self-Employment and Substantial Service Questionnaire Self-Employment Questionnaire	Form and Instruction
Form AA-4 (XX-XX) Propo Self-Employment and Substantial Service Questionnaire Self-Employment Questionnaire	Form and Instruction
AA-4 (06-23) Self-Employment and Substantial Service Questionnaire Form AA-4 (06-23).pdf	Form and Instruction
AA-4 (XX-XX) Propo Self-Employment and Substantial Service Questionnaire AA-4 (XX-XX) Proposed.pdf	Form and Instruction
Form AA-1 (01-18).pdf Application for Employee Annuity	IC Document
Form AA-3 (07-17).pdf Application for Spouse/Divorced Spouse Annuity	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 216.11-16

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	AA-4 (06-23)				No		Paper Only
Form and Instruction	AA-4 (XX-XX) Proposed				No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-22, Railroad Retirement, Survivor, and Pensioner Benefit System

FR Citation: 79 FR 58874

Number of Respondents: 1,019

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	1,019	-148	1,167
Annual IC Time Burden (Hours)	705	-102	807
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Application for Employee Annuity		05/20/2020
Application for Spouse/Divorced Spouse Annuity		05/12/2020

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

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