Modified Benefit Formula Questionnaire-Employer

Documents and Forms

Document Name Document Type
Privacy Act Statement 0477.doc Other-Privacy Act Statement (revised
PRA 0477.doc Other-Paperwork Reduction Act Statem
SSA-58 Modified Benefit Formula Questionnaire-Employer SSA-58 (revised).pdf Form
SSA-58 (current).pdf SSA-58 (current) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Modified Benefit Formula Questionnaire-Employer	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 404.1512-404.1515 20 CFR 416.912-416.915

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Other-Paperwork Reduction Act Statement Revised			PRA 0477.doc	No	Paper Only
Other-Privacy Act Statement (revised)			Privacy Act Statement 0477.doc	No	Paper Only
Form	SSA-58	Modified Benefit Formula Questionnaire-Employer	SSA-58 (revised).pdf	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 26,925	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	26,925	-3,075	30,000
Annual IC Time Burden (Hours)	1,346	-8,654	10,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-58 (current)	SSA-58 (current).pdf	08/03/2020

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