Information Collection

Certification of Low Birth Weight for SSI Eligibility

IC 9777 under ICR 201112-0960-001 · OMB 0960-0720.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0720 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-3830 Certification of Low Birth Weight for SSI Eligibility Form
SSA-3830 Certification of Low Birth Weight for SSI Eligibility SSA-3830 Revised Version.pdf Form
ssa3830.pdf SSA-3830 Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certification of Low Birth Weight for SSI Eligibility	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 416.931 20 CFR 416.926a(m) (7) and (8) 20 CFR 416.924

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-3830	Certification of Low Birth Weight for SSI Eligibility	SSA-3830 Revised Version.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: 27,500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	27,500	3,500	24,000
Annual IC Time Burden (Hours)	6,875	875	6,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-3830 Current Version	ssa3830.pdf	01/19/2012

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