Information Collection

Ssa-2855

IC 200252 under ICR 202410-0960-017 · OMB 0960-0481.

Documents and Forms

Document Name Document Type
Form SSA-2855 SSA-2855 Form and Instruction
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

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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	20,000	20,000
Annual IC Time Burden (Hours)	23,000	23,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-2855	SSA-2855 (current).pdf	10/23/2024

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