Statement of Care and Responsibility for Beneficiary

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0109 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-788 Statement of Care and Responsibility for Beneficiary Form
SSA-788 Statement of Care and Responsibility for Beneficiary SSA-6233 (revised).pdf Form
SSA-788 2012 (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 416.620 20 CFR 404.2025 20 CFR 408.620 20 CFR 408.625 20 CFR 404.2020 20 CFR 416.625

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-788	Statement of Care and Responsibility for Beneficiary	SSA-6233 (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: 130,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	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)	SSA-788 2012 (Current).pdf	08/10/2012

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