Request for Accommodation in Communication Method (paper form)

Request for Accommodation in Communication Method

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0777 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-9000 Request for Accommodation in Communication Method (paper form) Form and Instruction
SSA-9000 Request for Accommodation in Communication Method SSA-9000 (F).pdf Form and Instruction
Form SSA-9000 (0960-0777).doc SSA-9000 - Old Version IC Document

Information Collection (IC) Details

IC Title:	Request for Accommodation in Communication Method (paper form)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 85.51

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-9000	Request for Accommodation in Communication Method	SSA-9000 (F).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	250	-250	500
Annual IC Time Burden (Hours)	63	-62	125
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-9000 - Old Version	Form SSA-9000 (0960-0777).doc	07/26/2010

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