Information Collection

SSA-821-BK - Returned Via Mail

IC 273069 under ICR 202409-0960-008 · OMB 0960-0059.

Documents and Forms

Document Name Document Type
Form SSA-821-BK SSA-821-BK - Returned Via Mail Form
SSA-821 - Revised PA & PRA Statements.pdf Other-Revised Privacy Act and PRA St
SSA-821-BK Work Activity Report – Employee SSA-821-BK (revised).pdf www.ssa.gov Form
SSA-892-BK (Current).pdf SSA-821 - Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	SSA-821-BK - Returned Via Mail	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 404.1571-1576 20 CFR 416.971-976 20 CFR 404.1520(b) 20 CFR 404.1584-1593

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-821-BK	Work Activity Report â Employee	SSA-821-BK (revised).pdf	www.ssa.gov	Yes	No	Fillable Printable
Other-Revised Privacy Act and PRA Statements			SSA-821 - Revised PA & PRA Statements.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 192,990	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
Annual Number of Responses for this IC	192,990	192,990
Annual IC Time Burden (Hours)	176,908	176,908
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-821 - Current Version	SSA-892-BK (Current).pdf	12/16/2024

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