20 CFR 404.1503b(c) & 416.903b(c)

Evidence From Statutorily Excluded Medical Sources

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0803 can be found here:

Documents and Forms

Document Name Document Type
Draft BBA 812 Fact Sheet.pdf Instruction
Website - Draft Fact Sheet ScreenShots.pdf www.ssa.gov Instruction
Draft Sample Written Statement of Exclusion.pdf www;ssa.gov Other-Sample Template

Information Collection (IC) Details

IC Title:	20 CFR 404.1503b(c) & 416.903b(c)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 20 CFR 404.1503b(c) 20 CFR 416.903b(c)

Information Collection Instruments:

Document Type	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction	Website - Draft Fact Sheet ScreenShots.pdf	www.ssa.gov	Yes	No	Printable Only
Instruction	Draft BBA 812 Fact Sheet.pdf		No		Paper Only
Other-Sample Template	Draft Sample Written Statement of Exclusion.pdf	www;ssa.gov	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: 50	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	3,000	3,000
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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