View Information Collection Request (ICR) Package
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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:
0960-0508
ICR Reference No:
202411-0960-017
Status:
Active
Previous ICR Reference No:
202002-0960-007
Agency/Subagency:
SSA
Agency Tracking No:
Title:
SSA-L2765, Request for Self-Employment Information, SSA-L3365, Request for Employee Information, SSA-L4002, Request for Employer Information
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:
07/24/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/27/2024
Terms of Clearance:
Previous ToC continue to apply: "The agency revised the respondent estimate and burden to reflect that this ICR is currently inactive. If the agency intends to use this ICR prior to re-approval, it will submit a change request to OMB. Prior to any decision to re-initiate this information collection, the agency will consult with OMB about developing an electronic submission modality to facilitate the collection."
Inventory as of this Action
Requested
Previously Approved
Expiration Date
07/31/2028
36 Months From Approved
07/31/2025
Responses
3
0
3
Time Burden (Hours)
0
0
0
Cost Burden (Dollars)
31
0
0
Abstract:
The purpose of the collection relates to the application for benefits. SSA adds the reported earnings to the respondent’s Social Security record, thereby providing the necessary earnings information to establish the correct benefit amounts that the beneficiary is due. The collection is voluntary, the modality is paper, and respondents can complete the forms by themselves. SSA employees collect and process these forms for annual use. The respondents are individuals, or the employers of those individuals; we use employer addresses only when we do not have the individual’s correct address information.
Authorizing Statute(s):
US Code:
42 USC 405
Name of Law: Social Security Act
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
89 FR 74351
09/12/2024
30-day Notice:
Federal Register Citation:
Citation Date:
89 FR 88105
11/06/2024
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
3
IC Title
Form No.
Form Name
SSA-L2765, Request for Self-Employment Information
SSA-L2765
Request for Self-Employment Information
SSA-L3365, Request for Employee Information
SSA-L3365
Request for Employee Information
SSA-L4002, Request for Employer Information
SSA-L4002
Request for Employer Information
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
3
3
0
0
0
0
Annual Time Burden (Hours)
0
0
0
0
0
0
Annual Cost Burden (Dollars)
31
0
0
31
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$420
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
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
11/27/2024
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