Statement of Care and Responsibility for Beneficiary

Documents and Forms

Document Name Document Type
Form SSA-788 Statement of Care and Responsibility for Beneficiary Form
0109 Privacy Act Statement (revised).docx Other-Paper Reduction Act Statement
PRA Statement 0109 (revised).docx Other-Privacy Act Statement (revised
SSA-788 Statement of Care and Responsibility for Beneficiary Form SSA-788 (revised).pdf Form
Form SSA-788 (current).pdf SSA-788 - Current IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Statement of Care and Responsibility for Beneficiary	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 404.2025 20 CFR 408.620 20 CFR 408.625 20 CFR 404.2020 20 CFR 416.625 20 CFR 416.620

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-788	Statement of Care and Responsibility for Beneficiary	Form SSA-788 (revised).pdf	No	Fillable Printable
Other-Paper Reduction Act Statement revised			0109 Privacy Act Statement (revised).docx	No	Paper Only
Other-Privacy Act Statement (revised)			PRA Statement 0109 (revised).docx	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 130,000	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	130,000	130,000
Annual IC Time Burden (Hours)	21,667	21,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-788 - Current	Form SSA-788 (current).pdf	08/24/2021

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