SSA-5665-BK (Electronic)

Teacher Questionnaire; Request for Administrative Information

Documents and Forms

Document Name Document Type
Revised PA & PRA Statements - SSA-5665-BK.pdf Other-Revised PA & PRA Statements
SSA-5665-BK (Elect Teacher Questionnaire SSA-5665-BK - Revised.pdf Form and Instruction
SSA-5665-BK - Current.pdf SSA-5665-BK - Current IC Document

Information Collection (IC) Details

IC Title:	SSA-5665-BK (Electronic)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 416.1103(f)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SSA-5665-BK (Electronic)	Teacher Questionnaire	SSA-5665-BK - Revised.pdf		Yes	Yes	Fillable Fileable Signable
Other-Revised PA & PRA Statements			Revised PA & PRA Statements - SSA-5665-BK.pdf		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: 246,539	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 98 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	246,539	-46,836	293,375
Annual IC Time Burden (Hours)	164,359	-31,224	195,583
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-5665-BK - Current	SSA-5665-BK - Current.pdf	12/03/2020

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