Application for Benefits Under a U.S. International Social Security Agreement (Paper)

Application for Benefits Under a U.S. International Social Security Agreement

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0448 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-2490-BK Application for Benefits Under a U.S. International Social Security Agreement (Paper) Form
MCS Screens for the SSA-2490.pdf Other-database screens
0448 Privacy Act Statement revised.docx Other-Privacy Act Statement (revised
PRA Statement.doc Other-Paperwork Reduction Act Statem
SSA-2490-BK Application for Benefits Under a U.S. International Soci SSA-2490-Bk (Revise).pdf Form
SSA-2490-Bk (current).pdf SSA-2490-BK (current) IC Document

Information Collection (IC) Details

IC Title:	Application for Benefits Under a U.S. International Social Security Agreement (Paper)	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 404.1925

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-2490-BK	Application for Benefits Under a U.S. International Social Security Agreement	SSA-2490-Bk (Revise).pdf	No		Paper Only
Other-database screens			MCS Screens for the SSA-2490.pdf	Yes	Yes	Fillable Fileable Signable
Other-Privacy Act Statement (revised)			0448 Privacy Act Statement revised.docx	No		Paper Only
Other-Paperwork Reduction Act Statement Revised			PRA Statement.doc	No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,140	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	2,140	20	2,120
Annual IC Time Burden (Hours)	1,070	10	1,060
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-2490-BK (current)	SSA-2490-Bk (current).pdf	07/12/2017

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