Information Collection

Ssa-2855

IC 200252 under ICR 202012-0960-011 · OMB 0960-0481.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0481 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-2855 SSA-2855 Form and Instruction
Revised PA & PRA Statements.pdf Other-Revised PA & PRA Statements
SSA-2855 Statement of Funds You Recieve SSA-2855 - Revised.pdf Form and Instruction
SSA-2855 - Current.pdf Current SSA-2855 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SSA-2855	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 416.1103(f)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-2855	Statement of Funds You Recieve	SSA-2855 - Revised.pdf		No		Fillable Printable
Other-Revised PA & PRA Statements			Revised PA & PRA Statements.pdf		No		Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	20,000	0	20,000
Annual IC Time Burden (Hours)	5,000	1,667	3,333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-2855	SSA-2855 - Current.pdf	03/16/2021

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