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Certificate of Responsibility for Welfare and Care of Child Not In Applicant's Custody
Certificate of Responsibility for Welfare and Care of Child Not In Applicant's Custody
OMB: 0960-0019
IC ID: 8911
OMB.report
SSA
OMB 0960-0019
ICR 201810-0960-013
IC 8911
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0019 can be found here:
2022-05-31 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form SSA-781
Certificate of Responsibility for Welfare and Care of Child Not In Applicant's Custody
Form
0019 revised PAS.docx
Other-Revised Privacy Act Statement
SSA-781 Certificate of Responsibility for Welfare Care of a Chil
SSA-781 (revised).pdf
Form
SSA-781 (current).pdf
Certificate of Responsibility for Welfare Care of a Child Not in Applican'ts Custody
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Certificate of Responsibility for Welfare and Care of Child Not In Applicant's Custody
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
20 CFR 404.339-404.341
20 CFR 404.348-404.349
20 CFR 404.330
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
SSA-781
Certificate of Responsibility for Welfare Care of a Child Not in Applican'ts Custody
SSA-781 (revised).pdf
Yes
No
Fillable Printable
Other-Revised Privacy Act Statement 0019
0019 revised PAS.docx
Yes
Yes
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
14,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
14,000
0
0
0
0
14,000
Annual IC Time Burden (Hours)
2,333
0
0
0
0
2,333
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Certificate of Responsibility for Welfare Care of a Child Not in Applican'ts Custody
SSA-781 (current).pdf
11/14/2018
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.