View Information Collection (IC)

View Information Collection (IC)

IC Title:	Application for Benefits Under a U.S. International Social Security Agreement (Paper)	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 404.1925

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-2490-BK	Application for Benefits Under a U.S. International Social Security Agreement	SSA-2490-BK (revised).pdf		No		Paper Only
Other-database screens			MCS Screens for the SSA-2490.pdf		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: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	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	2,000	0	0	-24,700	0	26,700
Annual IC Time Burden (Hours)	1,000	0	0	-12,350	0	13,350
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-2490-BK (current)	SSA-2490-BK (current).pdf	06/20/2011

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