Revoking Authorization

Authorization for the Social Security Administration to Obtain Wage and Employment Information from Payroll Data Providers

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0807 can be found here:

Documents and Forms

Document Name Document Type
BBA 824 Intranet Final Screen Package OMB version 05182017.docx Other-Internet Screens
iClaim Screen for OMB 021517 (3).docx Other-Payroll Data Release Form Scre

Information Collection (IC) Details

IC Title:	Revoking Authorization	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Internet Screens			BBA 824 Intranet Final Screen Package OMB version 05182017.docx		Yes	Yes	Fillable Fileable Signable
Other-Payroll Data Release Form Screen			iClaim Screen for OMB 021517 (3).docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 191,673	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
Annual Number of Responses for this IC	191,673	191,673
Annual IC Time Burden (Hours)	31,946	31,946
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.