Information Collection

Ssa-9301

IC 9763 under ICR 201110-0960-005 · OMB 0960-0707.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0707 can be found here:

Documents and Forms

Document Name Document Type
SSA-9301 Revised Version.docx N/A conducted over telephone Other-Telephone Interview Script
SSA-9301 Current Version.docx SSA-9301 Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SSA-9301	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 418(b)(5) (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Telephone Interview Script			SSA-9301 Revised Version.docx	N/A conducted over telephone	No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,500	-1,500	5,000
Annual IC Time Burden (Hours)	1,750	-750	2,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-9301 Current Version	SSA-9301 Current Version.docx	11/21/2011

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