Renewal Certification - SSA-3194

Medical Permit Parking Application

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0624 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-3194 Renewal Certification - SSA-3194 Form and Instruction
SSA-3194 Renewal Certification SSA-3194 (2017) Mock-up.pdf Form and Instruction
ssa3194 (current).pdf Current SSA-3194 IC Document

Information Collection (IC) Details

IC Title:	Renewal Certification - SSA-3194	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 41 CFR 102-71.20 41 CFR 102-74.305 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-3194	Renewal Certification	SSA-3194 (2017) Mock-up.pdf		No		Paper Only

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 82	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	82	-11	93
Annual IC Time Burden (Hours)	7	-1	8
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-3194	ssa3194 (current).pdf	07/19/2017

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