View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0960-0759	ICR Reference No: 202204-0960-006
Status: Active	Previous ICR Reference No: 201901-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Certificate of Election for Reduced Widow(er)’s and Surviving Divorced Spouse’s Benefits
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/31/2023
	Date Received in OIRA: 09/02/2022
Terms of Clearance: Prior to reapproval, the agency will revisit Supporting Statement A Question 2 to more thoroughly describe why and how the SSA-4111 is used.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2026	36 Months From Approved	08/31/2023
Responses	30,000	0	30,000
Time Burden (Hours)	1,000	0	1,000
Cost Burden (Dollars)	0	0	0

Annual Cost to Federal Government: $31,801

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.