OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Discrimination Complaint Form

IC 9560 under ICR 202601-0960-007 · OMB 0960-0585.

Documents and Forms
Document Name
Document Type
Form and Instruction
Other-Revised PA Statement
Form and Instruction
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Discrimination Complaint Form
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction SSA-437-BK Discrimination Complaint Form SSA-437 (REVISED).pdf Yes No Fillable Fileable
Other-Revised PA Statement Revised PAS.docx No   Paper Only

Community and Social Services Social Services

 

600 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 600 0 0 100 0 500
Annual IC Time Burden (Hours) 750 0 0 250 0 500
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
SSA-437-BK - Current ssa-437 (current).pdf 04/24/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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