f) 20 CFR 411.560 - SSA-1401, Split Payment Situations

The Ticket to Work and Self-Sufficiency Program

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0644 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-1401 f) 20 CFR 411.560 - SSA-1401, Split Payment Situations Form
SSA-1401 - Revised PA & PRA Statements.pdf Other-Revised PA and PRA Statements
SSA-1401 Employment Network Split Payment Request Form SSA-1401 - Revised.pdf Form
SSA-1401 (current).pdf Current SSA-1401 IC Document

Information Collection (IC) Details

IC Title:	f) 20 CFR 411.560 - SSA-1401, Split Payment Situations	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 411.560

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-1401	Employment Network Split Payment Request Form	SSA-1401 - Revised.pdf		Yes	No	Printable Only
Other-Revised PA and PRA Statements			SSA-1401 - Revised PA & PRA Statements.pdf		Yes	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5	-95	100
Annual IC Time Burden (Hours)	2	-31	33
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-1401	SSA-1401 (current).pdf	02/09/2022

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