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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0508 can be found here:

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 Current SSA-L2765 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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,321	4,451	7,870
Annual IC Time Burden (Hours)	2,054	742	1,312
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-L2765	SSA-L2765 (current).pdf	01/06/2014

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