Information Collection

Claimant Travel Reimbursement Request

IC 179637 under ICR 201002-0960-013 · OMB 0960-0752.

Documents and Forms

Document Name Document Type
Form SSA-104 Claimant Travel Reimbursement Request Form
SSA-104 Claimant Travel Reimbursement Request SSA-104 (revised).pdf Form
SSA-104 (current).pdf Claimant Travel Reimbursement Request (current) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claimant Travel Reimbursement Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.999a-d

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-104	Claimant Travel Reimbursement Request	SSA-104 (revised).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 11,092	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	11,092	11,092
Annual IC Time Burden (Hours)	1,849	1,849
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Claimant Travel Reimbursement Request (current)	SSA-104 (current).pdf	05/18/2010

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