Application and Statement - SSA-3192

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⚠️ Notice: This information collection may be referencing outdated material.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-3192 Application and Statement - SSA-3192 Form and Instruction
SSA-3192 Application and Statement SSA-3192 (revised).pdf Form and Instruction
SSA-3192 current.pdf Current SSA-3192 IC Document

Information Collection (IC) Details

IC Title:	Application and Statement - SSA-3192	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-3192	Application and Statement	SSA-3192 (revised).pdf		No		Paper Only

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 390	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	390	390
Annual IC Time Burden (Hours)	195	195
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-3192	SSA-3192 current.pdf	02/07/2019

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