Information Collection

SSA-1372-BK (Domestic)--State/Local/Tribal Government

IC 182786 under ICR 202005-0960-003 · OMB 0960-0105.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0105 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-1372-BK SSA-1372-BK (Domestic)--State/Local/Tribal Government Form
0105 Privacy Act Statement (revised).docx Other-Revised Paperwork Reduction Ac
PRA 0105.docx Other-Revised Paperwork Reduction Ac
SSA-1372-BK Advanced Notice of Termination of Child's Benefits SSA-1372-BK (revised).pdf Form
SSA-1372-BK (current).pdf Advance Notice of Termincaiton fo Child's Benefits (current) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SSA-1372-BK (Domestic)--State/Local/Tribal Government	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 404.350-404.352 20 CFR 404.367-404.368

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-1372-BK	Advanced Notice of Termination of Child's Benefits	SSA-1372-BK (revised).pdf	No	Paper Only
Other-Revised Paperwork Reduction Act			0105 Privacy Act Statement (revised).docx	No	Paper Only
Other-Revised Paperwork Reduction Act Statement			PRA 0105.docx	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 209,861	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	209,861	110,011	99,850
Annual IC Time Burden (Hours)	10,493	5,500	4,993
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Advance Notice of Termincaiton fo Child's Benefits (current)	SSA-1372-BK (current).pdf	08/25/2020

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