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⚠️ Notice: This information collection may be referencing outdated material.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	Previously Approved
Annual Number of Responses for this IC	12,321	12,321
Annual IC Time Burden (Hours)	2,054	2,054
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-L2765	SSA-L2765(current).pdf	01/17/2017

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