Disability Report-Appeal 20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 405 subpart C, 422.140

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0144 can be found here:

Documents and Forms

Document Name Document Type
i3441-Current.doc s044a90.ssa.gov/apps6z/i3441/ee001gen.jsp Other-Internet Collection Screen
i3441 Proposed.doc s044a90.ssa.gov/apps6z/i3441/ee001gen.jsp Other-Internet Collection Screen

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Disability Report-Appeal 20 CFR 404.1512, 416.912, 404.916(c), 416.1416(c), 405 subpart C, 422.140	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internet Collection Screen			i3441-Current.doc	https://s044a90.ssa.gov/apps6z/i3441/ee001gen.jsp	Yes	Yes	Fillable Fileable
Other-Internet Collection Screen			i3441 Proposed.doc	https://s044a90.ssa.gov/apps6z/i3441/ee001gen.jsp	Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,112,720	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 64 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,112,720	1,112,720
Annual IC Time Burden (Hours)	924,967	924,967
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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