View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	SSA-5666 (Electronic)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.924(a)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-5666				Yes	Yes	Fillable Fileable Signable
Other-Revised PA & PRA Statements					Yes	Yes	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 91,186	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	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	91,186	0	0	-20,003	0	111,189
Annual IC Time Burden (Hours)	45,593	0	0	-10,002	0	55,595
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-5666 - Current		12/03/2020

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

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