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Important Information About Your Appeal, Waiver Rights, and Repayment Options (Paper Form)
Important Information About Your Appeal, Waiver Rights and Repayment Options
OMB: 0960-0779
IC ID: 191893
OMB.report
SSA
OMB 0960-0779
ICR 201507-0960-010
IC 191893
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0779 can be found here:
2022-01-13 - Revision of a currently approved collection
2018-11-14 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form SSA-3105
Important Information About Your Appeal, Waiver Rights, and Repayment Options (Paper Form)
Form and Instruction
SSA-3105 Important Information About Your Appeal, Waiver Rights,
ssa-3105(revised).pdf
Form and Instruction
ssa-3105(current).pdf
SSA-3105 Current Version
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Important Information About Your Appeal, Waiver Rights, and Repayment Options (Paper Form)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
20 CFR 404.502 - 404.521
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
SSA-3105
Important Information About Your Appeal, Waiver Rights, and Repayment Options
ssa-3105(revised).pdf
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
General Retirement and Disability
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
600,000
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
600,000
0
0
0
0
600,000
Annual IC Time Burden (Hours)
150,000
0
0
0
0
150,000
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
SSA-3105 Current Version
ssa-3105(current).pdf
10/15/2015
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.