SSA-L2765, Request for Self-Employment Information

SSA-L2765, Request for Self-Employment Information, SSA-L3365, Request for Employee Information, SSA-L4002, Request for Employer Information

Documents and Forms

Document Name Document Type
Form SSA-L2765 SSA-L2765, Request for Self-Employment Information Form
SSA-L2765 Request for Self-Employment Information SSA-L2765 - Revised.pdf Form
SSA-L2765 - Current.pdf SSA-L2765 - Current IC Document

Information Collection (IC) Details

IC Title:	SSA-L2765, Request for Self-Employment Information	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 422.120

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-L2765	Request for Self-Employment Information	SSA-L2765 - Revised.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: 12,321	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	12,321	12,321
Annual IC Time Burden (Hours)	2,054	2,054
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-L2765 - Current	SSA-L2765 - Current.pdf	04/01/2020

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