Information Collection

20 CFR 404.1503b(c) - Fact Sheet

IC 222015 under ICR 202607-0960-007 · OMB 0960-0803.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
BBA 812 - Model Response - For Sections 208 or 1632 of the Act.pdf www;ssa.gov	Other-Sample Template
BBA 812 - Model Response - For Section 1128 of the Act.pdf www.ssa.gov	Other-Sample Template
BBA 812 - Model Response - For Section 1129 of the Act.pdf www.ssa.gov	Other-Sample Template
BBA 812 - Fact Sheet - Initial Notice - Current.pdf BBA 812-Paper Fact Sheet-Current	IC Document
BBA 812 - Internet Fact Sheet Screen Shots - Current.docx BBA-812 - Internet Fact Sheet Screen Shots -Current	IC Document
BBA 812 - Follow Up Notice - Current.docx Sample Notice for Section 812-Current	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 416.903b(c) 20 CFR 404.1503b(c)

Information Collection Instruments:

table that charts list of instruments
Document Type	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Sample Template	www;ssa.gov	Yes	No	Printable Only
Other-Sample Template	www.ssa.gov	Yes	No	Printable Only
Other-Sample Template	www.ssa.gov	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: 2,670

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,670	2,070	600
Annual IC Time Burden (Hours)	890	690	200
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
BBA 812-Paper Fact Sheet-Current		07/05/2026
BBA-812 - Internet Fact Sheet Screen Shots -Current		07/05/2026
Sample Notice for Section 812-Current		07/05/2026

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

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