Identifying Information for Possible Direct Payment of Authorized Fees

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0730 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-1695 Identifying Information for Possible Direct Payment of Authorized Fees Form
Privacy Act Statement 0730.doc Other-Revised Privacy Act Statement
PRA 0730.doc Other-Revised Paperwork Reduction Ac
SSA-1695 Identifying Information for Possible Direct Payment of A ssa-1695 (revised).pdf Form
ssa-1695(current).pdf SSA-1695 Current Version IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Identifying Information for Possible Direct Payment of Authorized Fees	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form	SSA-1695	Identifying Information for Possible Direct Payment of Authorized Fees	ssa-1695 (revised).pdf	No	Paper Only
Other-Revised Privacy Act Statement			Privacy Act Statement 0730.doc	No	Printable Only
Other-Revised Paperwork Reduction Act			PRA 0730.doc	No	Printable Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,000	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	400,000	400,000
Annual IC Time Burden (Hours)	66,667	66,667
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-1695 Current Version	ssa-1695(current).pdf	04/09/2015

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