Information Collection

Statement of Self-Employment Income

IC 43691 under ICR 201502-0960-010 · OMB 0960-0046.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0046 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-766 Statement of Self-Employment Income Form
PRA 0046.doc Other-Paperwork Reduction Act
Privacy Act Statement Revised.doc Other-Privacy Act Statement (revised
SSA-766 Statement of Self-Employment Income SSA-766 (revised).pdf Form
ssa766(current).pdf SSA-766 Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Self-Employment Income	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 404.1096 20 CFR 404.610 20 CFR 404.110 20 CFR 404.611 20 CFR 404.101 20 CFR 422.405

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-766	Statement of Self-Employment Income	SSA-766 (revised).pdf	No	Paper Only
Other-Paperwork Reduction Act			PRA 0046.doc	No	Paper Only
Other-Privacy Act Statement (revised)			Privacy Act Statement Revised.doc	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,500	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	2,500	2,500
Annual IC Time Burden (Hours)	208	208
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-766 Current Version	ssa766(current).pdf	05/05/2015

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