Information Collection

EE 5A - Supplemental Employment Evidence

IC 251535 under ICR 202109-1240-002 · OMB 1240-0002.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0002 can be found here:

Documents and Forms

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Information Collection (IC) Details

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IC Title:	EE 5A - Supplemental Employment Evidence	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 30.112

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: DOL/OWCP-11	FR Citation: 81 FR 25868

Number of Respondents: 773	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
Annual Number of Responses for this IC	773	773
Annual IC Time Burden (Hours)	387	387
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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