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OMB Control No: 0960-0663	ICR Reference No: 202603-0960-009
Status: Received in OIRA	Previous ICR Reference No: 202207-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Private Printing and Modification of Prescribed Application and Other Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 04/28/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2026
Responses	150	150
Time Burden (Hours)	25	25
Cost Burden (Dollars)	0	0

Annual Cost to Federal Government: $2,288

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. No

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

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