Information Collection

SSA-120 (paper version)

IC 281311 under ICR 202607-0960-003 · OMB 0960-0791.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-120 Application for Access to SSA Systems SSA-120 (paper version)	Form
Privacy Act Statement (revised).docx	Other-Privacy Act Statement (revised
SSA-120 Application for Access to SSA Systems SSA-120 (revised).pdf	Form
SSA-120 (current).pdf SSA-120 (current)	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 401.45 26 CFR 31.6011(b)2 26 CFR 31.61091

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-120				No		Fillable Fileable Signable
Other-Privacy Act Statement (revised)					No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 685

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	685	685
Annual IC Time Burden (Hours)	23	23
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSA-120 (current)		07/24/2026

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

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